Patient Safety in the ICU
Safety in patient care has been of concern since the release of the Institute of Medicine Report in 1997 attributing human error to between 4 percent and 16 percent of sentinel events. However, the report did little to inspire medical professions to develop concerted actions to improve patient safety and reduce the frequency of deaths in hospitals resulting from human error. More recently, Rodziewicz and Hipskind (2019) cited medical errors as the leading cause of death in the United States. The authors contend that it remains challenging to “uncover a consistent cause of the errors and, even if found, to provide a consistent, viable solution that minimizes the chance of a recurrent event.” Medical errors remain a public health concern whose resolution requires identifying the root causes from that include the working environment, equipment distribution, working conditions and skills among personnel, and lack of effective communication amongst staff.
Human factors or ergonomics are individual components in the treatment of patients in hospitals. Thus, systems governing treatment processes in hospitals should be based on the nature of the task and the understanding of human behavior, thereby requiring a multi-disciplinary approach (Rodziewicz and Hipskind, 2019). This approach involves the input of multiple stakeholders in and without the hospital, and the collaboration of teams rooted in specialized knowledge, equipment delivery, communication, and a functional environment. These attributes result in reduced medical errors in the ICU setting. The fishbone diagram below is a summary of the causes and effects of factors resulting in an increase of mortality in ICUs. As earlier indicated, the environment, equipment, people, and communication are the primary cause of deaths in the ICU.
Source: Eleanor Wilkinson, 2019.
Communication among caregivers is critical for any functional team (Despins, 2009).
Citing a report by The Joint Commission National Patient Safety, Despins contends that ineffective communication is among the leading causes of sentinel events. The multinational
Sentinel Events Evaluation study indicates that over 20 percent of ICU patients experience critical incidents following the lack of adequate communication between staff (Ellison, 2015). According to Ellison, reporting systems are among the non-technical skills that lead to increased frequency in critical incidents. The author contends that among the common forms of errors in the ICU included inability by clinicians to “communicate order changes to nursing staff, incorrect patient information passed between different teams, and inadequate information dissemination on severely ill patients transferred to ICU” (Elisson, 2015). In their resolve, the authors poised that communication between teams working in the ICU was critical following the multitude of activities requiring effective communication.
Another aspect of communication in the ICU found inhibiting effective communication is the mode of transmission of data. The consensus among medical professionals is that digital data transmission is more effective than verbal or paper-based communication (De Georgia et al., 2015). The authors contend that critical care “involves highly complex decision making often involving intense data; however, the approach of data collection and management remains unchanged.” It remains of concern the large volumes of data are collected from multiple sources and reviewed retrospectively. In this regard, De Georgia et al. raise concerns over the inability of medical personnel working in the ICU to convert data from the numerous types of equipment present to a digital format that can be stored or sent offsite. The limited device interoperability and integration, and the challenges in analytical approaches “provide little insight into the patient’s actual pathophysiologic state.” Unfortunately, even with modern clinical information systems present in hospitals, limitations remain on the acquisition, synchronizing, integrating, analyzing, and transmitting data. However, these challenges are surmountable if medical personnel can effectively communicate with each other and send available data digitally as the world awaits the development of integrated critical care informatics capable of supporting clinical decisions making and with data transmissions capabilities.
For years, medical professionals have grappled with the shortage of medical equipment, low-quality equipment, or poor maintenance of equipment. Moyimane et al. (2017) contend that the lack of medical equipment adversely influences patients, particularly those in the ICU. The challenge of lack of medical supplies resulting from supply chain inefficiencies has been ongoing in the United States. Guillot (2018) asserts that inventory management fails to meet the demand for medical equipment. In instances when suppliers can meet demand, Guillot postulates that many facilities order, replenish a supply their hospitals in an inefficient and costly manner. In this regard, medical distribution should be automated. According to Guillot, “automating hospital supply chains can improve visibility and enable more accurate forecasting as well as reduce costs throughout the healthcare continuum.”
The location of the medical room can influence the morbidity and mortality rates among ICU patients. A study by Okech (2014) found critically ill patients, particularly in countries in the global south, did not have access to ICUs or the ICU setups lacked in essential equipment and inconsistent or had poorly maintained equipment and had faulty
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layout. In the United States, similar challenges exist regarding the defective plan of the ICU, which, according to Reiling and Murphy (2008), affects patient safety. The authors contend that the hospital layout, with its technology and equipment, has not been a concern of many scholars, yet, billions of dollars are spent in these facilities. Cognitive psychologists share similar sentiments. They argue that the physical environment significantly influences the safety and human performance (Leape, 1994). As such, it is critical to understand the interrelationship between the context in which humans work and the tools they use particularly in healthcare, whereby, the performance of the medical personnel is dependent on the environment.
Indeed, conditions for errors are exacerbated by organizational factors. Reiling and Murphy (2008) argue that faulty layouts in hospitals are “latent conditions that may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system’s defenses.” Nonetheless, such latent conditions can be identified and remedied, thereby preventing adverse events from occurring. As such, the location of the medical room can be attributed to specific medical errors and not others.
According to Reiling and Murphy (2008), such faulty layout occur following the “blunt end, where administrators, the work environment, and resources determine the processes of care delivery.” Though unintentionally created, these underlying conditions can be reduced by researching before designing a hospital layout, or designing facilities, particularly the medical room, that is movable. Furthermore, by targeting human factors in the design of hospital and ICU layouts, Reiling and Murphy (2008) contend that underlying conditions and cognitive failures can be kept at a minimum and consequently, improve patient safety.
Trends in hospital use and staffing patterns resulting in nurses and other personnel overworking remains potentially hazardous for patient safety. Nurses, in a study conducted by Rodgers et al. (2004), reported deficiencies in working conditions that have been reported for decades citing long and unpredictable working shifts and poor working condition as the leading contributor to error. Glette, Aase, and Wiig (2017) cited reasons for irregular working shifts as resulting from understaffing. The authors contend that patient safety and the occurrence of sentinel events results from understaffing, sentiments shared by many scholars, including Kiekkas et al. (2019). Although the authors did not find an increase in ICU mortality among nurses with an increased workload, it remains possible that overworking nurses and understaffing has an influence on the prevalence of sentinel events. ICU patients require individual care by adequately matching personnel the number of patients. Hospitals should also keep patient nurse’s workload if they are to reduce the severity of sentinel events.
Scholarly evidence point sentinel event in ICUs as resulting from the environment, communication challenges, staffing issues, and logistics and challenges with the medical supply chain. Nonetheless, multiple scholars have found ways to address these challenges that include ensuring adequate staffing of nurses, developing communication strategies that circumvent the current lack of technology in data transmission, implementing new supply chain strategies to overcome inventory management challenges, and placing emphasis on the design and layout of hospital plans. These initiatives improve service delivery, ensure adequate care is provided to ICU patients, and reduce morbidity and mortality rates in the ICU.
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