An Analysis of Near Misses Identified by Anesthesia Providers in the Intensive Care Unit

Medscape

 Finally, the rate of near misses reported in the ICU and OR was similar. Although this may be due to a bias in the type of reporting system used, it also suggests anesthesiologist involvement in the ICU may result in lower event rates.

..... Existing literature on adverse events and near misses in the ICU is primarily based on incident reports submitted by critical care nurses and intensivists.^[4–9] To our knowledge, this is the first study evaluating patient safety in the ICU from the unique perspective of the anesthesiologist. The results of our study differ from the results of previous studies, supporting our hypothesis that anesthesia providers can highlight systems weaknesses and causal mechanisms in the ICU not identified by other personnel. As compared to previous work on critical incidents in the ICU by Donchin, et al., a larger proportion of near misses from our study occurred at night or on the weekend,^[14] which could imply that decreased staffing in the ICU on off-hours impacts the ability of critical care providers to recognize, react to, and report near misses and adverse events.....