Critical incident reporting in the intensive care unit

Anaesthesia. 1997 May;52(5):403-9. doi: 10.1111/j.1365-2044.1997.094-az0085.x.


Critical incident reporting was introduced into the intensive care unit (ICU) as part of the development of a quality assurance programme within our department. Over a 3-year period 281 critical incidents were reported. Factors relating to causation, detection and prevention of critical incidents were sought. Detection of a critical incident in over 50% of cases resulted from direct observation of the patient while monitoring systems accounted for a further 27%. No physiological changes were observed in 54% of critical incidents. The most common incidents reported concerned airway management and invasive lines, tubes and drains. Human error was a factor in 55% of incidents while violations of standard practice contributed to 28%. Critical incident reporting was effective in revealing latent errors in our "system' and clarifying the role of human error in the generation of incidents. It has proven to be a useful technique to highlight problems previously undetected in our quality assurance programme. Improvements in quality of care following implementation of preventative strategies await further assessment.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Child
  • Child, Preschool
  • Equipment Failure
  • Hong Kong
  • Humans
  • Intensive Care Units / standards*
  • Medical Errors
  • Monitoring, Physiologic
  • Program Evaluation
  • Prospective Studies
  • Quality Assurance, Health Care*
  • Risk Management / methods*