A MULTIFACETED PROGRAM FOR IMPROVING QUALITY OF CARE IN ICUs
(IATROREF STUDY).
MAITE GARROUSTE ORGEAS, MD, LILIA SOUFIR, MD, ALEXIS TABAH, MD,
CAROLE SCHWEBEL, MD, AURELIEN VESIN, MSC, CHRISTOPHE ADRIE, MD,
MARIE THUONG, MD, JEAN FRANCOIS TIMSIT, MD, PHD.
On behalf of the Oucomerea Study Group
Corresponding author and requests for reprints: Dr Maité Garrouste-Orgeas, Service de
Réanimation Médico-Chirurgicale, Groupe Hospitalier Paris Saint Joseph, 185 rue Raymond
Losserand, 75014 Paris, France Tel: +33 144 123 415
Fax: +33 144 123 280
E-Mail: mgarrouste@outcomerea.org, mgarrouste@hpsj.fr
SUPPLEMENTAL DIGITAL CONTENT
Each multifaceted safety program included three components: an on-site educational slideshow for all ICU healthcare providers, printed educational material which was a pocket card
showing recommendations or advice about preventing the target medical error, and qualityimprovement sessions twice a month.
The pocket cards were used for preventing the selected medical errors.
They have been translated to English language for this electronic supplement.
OUTLINE
Figure E1. Insulin therapy in the ICU, side A
page 3
Figure E2. Insulin therapy in the ICU, side B
page 4
Figure E3. Prescribing anticoagulants in the ICU, side A
page 5
Figure E4. Prescribing anticoagulant sin the ICU, side B
page 6
Figure E5. Unplanned extubation, side A
page 7
Figure E6. Accidental catheter removal, side B
page 8
Table E1. Definition of medical errors
page 9
Table E2. Characteristics of the 15,014 patient-days
page 10
Table E3. Harms associated with medical errors in the study patients
page 11-12
Table E4. Impact of the anticoagulant safety program
page 13-14
Anticoagulant prescription errors were compared between
the baseline period and the implementation and post-implementation
periods.
2
Figure E1. Insulin therapy in the ICU, side A
3
Figure E2. Insulin therapy in the ICU, side B
4
Figure E3. Prescribing anticoagulants in the ICU, side A
5
Figure E4. Prescribing anticoagulants in the ICU, side B
6
Figure E5. Unplanned extubation, side A
7
Figure E6. Accidental catheter removal, side B
8
Table E1. Definition of medical errors
Medical errors
Error administering anticoagulant
medication
Error prescribing anticoagulant
medication
Error administering insulin
Accidental removal of a central venous
catheter
Accidental extubation
Definitions
Anticoagulant therapy is not given as
prescribed. The divergence may relate to the
planning and/or execution of the prescription:
drug given, dosage, preparation and
administration modalities, dosing times, or
dosing intervals.
Failure to comply with recommendations
(learned societies, department protocols, local
drug committees) regarding the indications,
dosage, administration modalities,
contraindications, drug interactions, or
laboratory monitoring of anticoagulant
treatment.
Insulin therapy is not given as prescribed
(including as per department protocol). The
divergence may relate to the planning and/or
execution of the prescription: drug given,
dosage, or preparation and administration
modalities.
Unplanned complete removal of a central
venous catheter by the patient or by a
healthcare worker during care or manipulation
of the catheter
Unplanned extubation
9
Table E2. Characteristics of the 15,014 patient-days
Variables
ICU 1
ICU 2
ICU 3
5890 (100)
5465 (100)
3659 (100)
Mechanical ventilation
2673 (45.4)
2771 (50.7)
1531 (41.8)
Noninvasive ventilation
403 (6.8)
661 (12.1)
161 (4.4)
Central venous catheter
4302 (73)
3840 (70.3)
1248 (34.1)
Arterial catheter
2531 (43)
2217 (40.6)
637 (17.4)
Insulin (IV and subcutaneous)
4582 (77.8)
3603 (65.9)
2567 (70.2)
Vasoactive drugs a
1889 (32.1)
1624 (29.7)
721 (19.7)
Prophylactic LMWH
1516 (25.7)
2380 (43.5)
1605 (43.5)
Therapeutic LMWH
67 (1.1)
217 (4)
241 (6.6)
Prophylactic heparin
1093 (18.6)
1057 (19.3)
431 (11.8)
Therapeutic heparin
1260 (21.4)
1101 (20.1)
333 (9.1)
Sedatives b
3327 (56.5)
3029 (55.4)
1378 (37.7)
587 (10)
291 (5.3)
219 (48)
Number of days, n (%)
Procedures ≥1 day, n (%)
Treatments ≥ 1 day, n (%)
Renal replacement therapy, n (%)
LMHW, low-molecular-weight heparin.
a
Adrenaline and noradrenaline
b
Benzodiazepines and opioids
10
Table E3. Harms associated with medical errors in the study patients
Medical errors
Anticoagulant prescription errors, n=204
Anticoagulant administration errors, n=79
Insulin administration errors, n=8142
Accidental removal of a central venous
catheter, n=28
Unplanned extubation
Accidental extubation, n=15
Self-extubation, n=52
Symptoms a
Hemorrhage
Hematoma
Arterial thrombosis
Venous thrombosis
Pulmonary embolism
Other
No consequence
Hemorrhage
No consequence
3
1
1
2
7
7
191
1
78
Hypoglycemia ≤54 mg/dl
Hyperglycemia ≥200 mg/dl
Coma
No consequence
No consequence
Hematoma
Hemorrhage
Death b
138
1225
1
6780
20
1
3
1
Oxygen saturation <80%
Aspiration
No consequence
Oxygen saturation <80%
Cardiac arrest
No consequence
Additional treatment a
Transfusion
4
Surgical treatment
2
No treatment
200
Transfusion
Surgical treatment
No treatment
Monitoring reinforced
No treatment
1
1
78
2
8140
Transfusion
Insertion of another catheter
Other
No treatment
3
8
1
17
5
5
7
Re-intubation
NIV
Oxygen
Antibiotics
No treatment
12
2
4
1
1
11
1
41
Re-intubation
NIV
Oxygen
Expanders
20
4
20
3
11
Cardiac massage
No treatment
1
18
CVC, central venous catheter; NIV, non-invasive ventilation.
a
For each adverse event, the consequences and treatment were predefined. Some adverse events had more than one consequence and/or
treatment.
b The
death was due to cardiac arrest following accidental catheter removal due to a fall.
12
Table E4. Impact of the anticoagulant safety program. Anticoagulant prescription errors were compared between the baseline period and the
implementation and post-implementation periods.
Study period
Baseline
OR (95%CI) a
No MEs
MEs
N (%)
N (%)
1614
120
(93.1)
(6.9)
228
(89.1)
28 (10.9)
1
704
(93.5)
49 (6.5)
0.49 (0.28-0.86)
332
(92.5)
27 (7.5)
0.49 (0.26-0.90)
OR (95%CI) a
P value
OR (95%CI) a
P value
P value
observational
period b
256 ICU stays
Before
0.0026
1
implementation
753 ICU stays
During
0.99 (0.57-1.73)
0.97
1
implementation
13
359 ICU stays
After
350
(95.6)
16 (4.4)
0.26 (0.12 -0.54)
0.53 (0.25-1.12)
0.10
implementation
366 ICU stays
MEs, medical errors; OR, odds ratio; CI, confidence interval; ICU, intensive care unit.
a
Hierarchical logistic regression (centre-patient) adjusted on factors significantly associated with occurrence (ICU stay length, heparin treatment,
presence of a venous catheter, and presence of a chronic cardiovascular disease defined by the Knaus classification [14]). The AUC value of
0.838 (95% CI: 0.79-0.88) indicated good explanatory power of the adjustment model.
b Baseline
period between January, 1, 2007 and February, 1, 2007, during which the ICU staff members were not aware of the study.
14