Patient safety

The nature of critical illness makes patients particularly vulnerable. They noften cannot communicate or react normally to protect themselves. Normal defence mechanisms are breached by various tubes and catheters, increasing the risk of infection. Complex drug treatment regimens increase the risk of adverse reactions. Immobility increases the risk of muscle wasting or thromboembolism. It can be unclear whether deterioration in a patient’s condition is a result of the disease or the treatment.

Protection in a complex environment

The critical care team must deal with an increasing array of data on multiple organ systems, support devices, monitors, treatment, and evidence on which to make decisions. Without some decision support aids, it is easy to miss some issues, with patient harm as a possible consequence. Decision support in its simplest form includes aide memoires to remind the team of what they should be doing. The Fast Hug mnemonic described in the table opposite is one such tool to ensure some of the basics of critical care are not forgotten. Other aides include communication sheets and structured record systems.

One of the most common causes of treatment error relates to drug prescription and administration. Electronic prescribing from templates

will reduce errors associated with poor handwriting but these are not foolproof.

Learning from mistakes

Learning from mistakes is fundamental to the improvement of patient safety. Incident reporting systems are now widespread amongst Critical

Care Units to:

• Ensure action is taken to prevent similar incidents in the future.

• Fulfi ll legal duties to report certain kinds of accident, violent incidents, dangerous occurrences, and occupational ill health.

• Ensure accurate information is collected to identify trends and take steps to prevent similar incidents from re-occurring.

• Provide evidence in pursuance of litigation claims, both for and against the hospital.

• Record incidents of particular interest for quality assurance, including the ability to demonstrate accident reductions, as part of a risk

management strategy.

It is essential that confi dentiality is maintained and disciplinary action avoided, except where acts or omissions are malicious, criminal, or constitute gross or repeated misconduct.

Deliberate harm

Because critically ill patients are vulnerable, the possibility of deliberate harm should be borne in mind. In order to protect patients, staff must undergo pre-employment health and criminal records' checks. Staff must be vigilant to ensure visitors are left with no opportunity to harm the patients. There must be clear record keeping and review by all members of the multidisciplinary critical care team to ensure unexpected changes in condition are recognised. Because deliberate harm is uncommon, recognition requires a high index of suspicion.

Fast Hug

Feeding	Oral or enteral preferred to parenteral
Analgesia	The minimum amount to avoid pain
Sedation	The minimum amount to achieve a calm patient
Thromboprohylaxis	Low molecular weight heparin
Head of bed elevated	30° head up if not contraindicated
Ulcer prophylaxis	In patients in whom evidence of benefi t
Glucose control	Tight glycaemic control protocol