Background: Learning from adverse events and near misses may reduce the incidence of preventable errors.\nCurrent literature on adverse events and near misses in the ICU focuses on errors reported by nurses and\nintensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and\nsystem weaknesses not identified by other providers, and may differ in character and causality from near misses in\nother anesthesia locations.\nMethods: We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We\ncompared causative mechanisms of ICU near misses with near misses in other anesthesia locations.\nResults: A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal\nmechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses\nfrom the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be\nassociated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated\nwith equipment issues (23 % vs. 48 %, p = 0.02).\nConclusions: A limited number of causal mechanisms explained the majority of ICU near misses, providing targets\nfor quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist\nconsultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the\nICU patient safety movement.
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