The Australian Incident Monitoring Study in intensive care: AIMS-ICU. An analysis of the first year of reporting.

Publisher's copy made available with the permission of the publisher Copyright © 1996 Australian Society of AnaesthetistsThe AIMS-ICU project is a national study set up to develop, introduce and evaluate an anonymous voluntary incident reporting system for intensive care. ICU staff members reported events which could have reduced, or did reduce, the safety margin for the patient. Seven ICUs contributed 536 reports, which identified 610 incidents involving the airway (20%), procedures (23%), drugs (28%), patient environment (21%), and ICU management (9%). Incidents were detected most frequently by rechecking the patient or the equipment, or by prior experience. No ill effects or only minor ones were experienced by most patients (short-term 76%, long-term 92%) as a result of the incident. Multiple contributing factors were identified, 33% system-based and 66% human factor-based. Incident monitoring promises to be a useful technique for improving patient safety in the ICU, when sufficient data have been collected to allow analysis of sets of incidents in defined “clinical situations”.U. Beckmann, I. Baldwin, G.K. Hart, W.B. Runcima

The Superconducting Proximity Effect as a Tool to Investigate Metal Films and Interfaces

052The superconducting proximity effect is measured in sandwiches of thin Pb films and the alkali metals Cs, Rb, K and Na. The $T_{c}$-dependence provides information about the interface barriers between Pb and the alkalis. Such a barrier is particularly large in Pb/Cs sandwiches. It is not due to impurities or oxydation. In the presence of a sufficiently strong barrier a special form of the Cooper limit can be applied to calculate the transition temperature of the sandwich

CO2 Increase: Questions Beyond Climate Change

The increase of the tropospheric C02 (carbon dioxide) concentration is considered by scientists all over the world to be an alarming signal, as becomes evident from the huge amount of literature on the subject. The so-called greenhouse-gas effect, or, more precisely, its anthropogenic component, is mainly caused by the C02 increase. However, other trace gases have also contributed their share. Far-reaching climatic changes, a temperature increase in the tropospheric air, especially in the polar region, as well as a gradual melting of the Greenland and Antarctic ice with a simultaneous rise of the seawater level, are being predicted as a consequence of the greenhouse effect. In addition to these gloomy prospects a new hypothesis has developed: The biological consequences of the evolution of a changed composition of the air could be hazardous to man and nature

The Australian Incident Monitoring Study in Intensive Care: AIMS-ICU. The development and evaluation of an incident reporting system in intensive care

Publisher's copy made available with the permission of the publisher © 1996 Australian Society of AnaesthetistsIntensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.U. Beckman, L.F. West, G.J. Groombridge, I. Baldwin, G.K. Hart, D.G. Clayton, R.K. Webb, W.B. Runcima