Working group on Quality Improvement

Aims and Missions

Head

Activities

SEE 2 (Sentinel Events Evaluation 2) One-day cross-sectional International study on parenteral medication errors in intensive care.

After the recently published first SEE study (available at www.esicm.org as article of the month October) the RG on Quality Improvement will perform SEE 2 in January 2007. The first SEE study has revealed that patient safety is an urgent issue in ICUs all over the world. In 205 participating ICUs 38 unintended events per 100 patient days were observed during the 24h study period. Medication errors occurred with considerable frequency. Now a next step in the SEE project is focused on causes and measures of error prevention. The upcoming SEE 2 study aims to determine the frequency, characteristics, and contributing factors of parenteral medication errors at the administration stage and to assess related preventive measures. This topic was choosen because it carries a particular high potential for serious patient harm and provides an important area for the prevention of unintended events.

SEE 2 looks at parenteral medication errors at the administration stage matching the definition of a sentinel event as occurrence that did or could have done harm to the patient. The SEE 2 study is designed as a multicentre, multinational, one-point (single-day) observational study. SEE 2 will take place over a period of 24 hours. Participating ICUs need to choose one out of two available study days (either 17th or 24th January 2007). Data will be collected by means of anonymous questionnaires filled out by nurses and intensivists. Because of the 24-hour format, the study workload for a single ICU will be minimal.

The SEE 2 study protocol is available at www.hsro-esicm.org (SEE2 / Overview).

Registration for the SEE study and data transmission will be done exclusively on the Internet. To register online for this study, go to www.hsro-esicm.org and follow the link “SEE 2 study.” All intensivists and ICUs over the world are encouraged to participate in this second step of a multicentre, multinational study project on patient safety.

Meetings agenda and minutes

The next meeting of the group will be held on Monday 8 October 2007 from 11.30 to 12.30 in room 43 of the Internationales Congress Centrum Berlin (ICC Berlin), Neue Kantstrasse- 14057 Berlin.

Useful Link

Section Health Service Research & Outcome