Acute decompensation after removing a central line: Practical approaches to increasing safety in the intensive care unit

Peter J. Pronovost, Albert W. Wu, J. Bryan Sexton

Research output: Contribution to journalReview articlepeer-review

79 Scopus citations

Abstract

Intensive care is one of the largest, most expensive, and complex components of U.S. health care. Errors and the resulting adverse events are, however, common in intensive care units (ICUs). Theories about errors in high-risk environments, developed by aviation and other industries, provide insight into why ICUs are prone to errors. Complex systems-of which ICUs are certainly an example-are breeding grounds for errors because interdependent components interact in unexpected ways. To achieve favorable outcomes, ICUs require that many processes occur in sequence. For example, patients are cared for by many providers with varying levels of expertise across several disciplines, and these providers use highly sensitive and potentially dangerous technologies and medications. Such complex systems require careful planning, excellent teamwork and communication, and designed redundancies to recheck for proper care processes. This paper provides a practical framework for improving patient safety.

Original languageEnglish (US)
Pages (from-to)1025-1033
Number of pages9
JournalAnnals of internal medicine
Volume140
Issue number12
DOIs
StatePublished - Jun 15 2004

ASJC Scopus subject areas

  • Internal Medicine

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