From: Reporting of unintended events in an intensive care unit: comparison between staff and observer
ICU where the UE has occurred | Shift of UE detection: Morning |
Reporter's qualification: Nurse, Physician | Afternoon |
Date of detection | Night |
Type of UE: Problems with airway/mechanical ventilation | Type of UE: Problems with catheter/drain/probes |
Accidental extubation | Unplanned removal |
Unplanned reintubation | Dislodgement |
Tracheal tube obstruction | Inappropriate opening |
Tracheal cuff leakage | Inappropriate disconnection |
Incorrect ventilator setting | |
Ventilator auto cycling | Type of UE: Problems with medication |
Turn off of heated humidifier | Prescription error |
Turn off of ventilator alarms | Transcription error |
Wrong dose | |
Type of UE: patient management: | Wrong route of administration |
Delayed treatment | |
Incorrect patient positioning | Type of UE: unit management |
Documentation lacking | Organization |
Documentation reported incorrectly or inaccurately | Communication |
Equipment failure | |
Turn off of oxygen saturationalarm | |
Other problem:................................ | |
Severity of the unintended event | |
Intercepted by the staff | |
Self resolving | |
Minor | |
Serious |