| Health services for the most part still depend on the oral transmission of information. Failures of communication are involved in 37% of the human errors committed in the intensive care unit (ICU) resulting in increased patient harm, length of stay (LOS) and resource use. Preliminary data have indicated that an explicit approach to rounds in an ICU, clearly reporting daily plans improves communication of providers and reduces ICU LOS. Objective: To increase patient safety by improving communication by introducing explicit daily goals According to the much-quoted Institute of Medicine (IOM) report To err is human, between 44,000 and 98,000 patients die each year in the USA as a result of clinical errors (1). Medical errors pose a significant threat to patients and incur substantial costs to society (2). A recent Dutch survey by TNS NIPO commissioned by the NICTIZ (National IT Institute for Healthcare) and NPCF (Dutch Patient Consumer Federation) has indicated that approximately 161,000 patients were affected last year by errors in the transfer of medical information. Annual costs of these errors in the Netherlands amount to approximately 1.4 billion euros (3). The likelihood of adverse events and errors increases with the intensity of care, the severity of illness and the complexity of the care-providing system (4). Especially in the intensive care setting the opportunity for clinical errors increases due to the complexity of patients problems and the frequency of (invasive) interventions. The concerns on the safe management of the acutely ill patient are underscored by a recent series of reviews in The Lancet by leading intensivists (5-8). Objective - To compare patient safety, estimated by the duration of ICU and post ICU hospital stay, the duration of mechanical ventilation plus the incidence of in errors per patient per ICU admission day (errors of commission and omission) and to compare the costs following the step-wise introduction of: 1. Extensive monitoring of errors In the ICU, the care team must perform many specific tasks on a daily basis including the implementation of treatments or the removal of tubes and catheters. To manage this work, the care team of all three shifts must univocally understand the daily goals of care. However, in daily practice this proves to be a problem. Pronovost et al for instance have demonstrated that after the daily rounds less than 10% of the residents and nurses understood the goals of care for the day for individual patients (17). It was felt that the discussion during rounds often center around pathophysiology, pharmacology, and available evidence, yet fail to develop explicit patient goals. Pilot exploration in our department has underscored the fact that this is a commonly encountered problem. It has been demonstrated that an explicit approach to rounds in an ICU, clearly reporting daily plans, improves both communication and satisfaction of providers (18). Pronovost, therefore, implemented a daily goals form (DGF) in their ICU in order to improve the effectiveness of communication during patient care rounds and to improve communication both within and between care teams. In addition, the DGF acts as a memory aid for the task to be completed that day. The form is completed by the staff during rounds for each individual patient, stating the tasks to be completed, the care plan, and communication plan (discussions with patient/family or other care givers). The form is signed by the fellow and/or intensivist and discussed with the patients nurse before moving on to the next patient. All members of the care team of the patient, both physicians and nurses, are required to review these goals during their shift, and check the form. After implementing the DGF, more than 95% of nurses and residents understood the goals of care for the day. Intensive care LOS decreased from a mean of 2.2 days to 1.1 days (17). These preliminary results, however, did not establish a causal relation between using the daily goals sheet and the reduced LOS. Although not monitored, the reduced incidence of errors is likely to have contributed to the positive outcome. |
