Preventable Deaths in the ICU

A hospital’s intensive care unit is where patients with the most serious health conditions are treated. But even critical ICU patients suffer deaths that are preventable, and one hospital set out to determine how to stop this from happening.

Medical errors have been estimated in several research efforts to kill hundreds of thousands of people every year in this country.  Some of the most common serious medical errors are:

• Misdiagnosis – missed diagnosis, delayed diagnosis, incorrect diagnosis
• Medication errors – wrong dosage, wrong medication, wrong delivery manner
• Hospital-acquired infections - Methicillin-resistant Staphylococcus aureus

Errors in the ICU

All these medical treatment mistakes can happen to patients throughout any hospital. Because of the serious nature of ICU patients, often times they face challenging treatments and questionable outcomes.  But this does not mean every ICU death is unavoidable.

That’s why, beginning in 2013, a medical center in California decided to identify preventable deaths in its ICU and develop a plan to reduce the factors that cause them. The study that resulted from this effort was published in the March 2021 issue of American Journal of Critical Care.

The study (“Rapid Mortality Review in the Intensive Care Unit: An In-Person, Multidisciplinary Improvement Initiative”) was an internal five-year review of ICU patient deaths at Ronald Reagan University of California Los Angeles Medical Center. The study period was 2013 through 2018.

In that time the hospital developed rapid mortality review teams. These teams of medical professionals examined ICU patient deaths. The reviews included patient charts and speaking with the treatment providers.

The teams determined that between 2013 and 2018 7% of the ICU patient deaths were preventable. (There could have been even more preventable deaths but the teams did not review about 20% of the ICU deaths in the five-year timeframe.)

That was the first step in the process: identifying which ICU patient deaths should have been avoided.  The second step, documented in the study, was to identify mistakes made during medical treatment in the ICU and then develop protocols to eliminate those mistakes from happening again.

The review teams identified causes for the ICU preventable deaths more than half of the time (54%). The process to identify them involved asking the treatment staff if they felt the healthcare provided to the patient was lacking.  If the answer was “yes,” then further investigation followed.

Causes of Preventable ICU Patient Deaths

This process helped to determine leading issues dealing with preventable patient deaths, which included:

• Poor communication and teamwork
• Delays in medical care
• Medical errors
• Hospital-acquired infections
• Procedural complications
• Systems-related, e.g., lack of protocols

Hospital Action Items to Improve Patient Care

Still another step in this review process was to develop a list of actions items – specific tasks that could reduce medical mistakes and preventable deaths in the ICU.

These included:

• Verbal patient handoffs between attending physicians
• Better nursing documentation, especially during late night into early morning
• Ensuring medical devices are working properly
• Focusing on the wellness of residents in July and August, months when they first experience ICU trauma
• Educational efforts on hospital policies

All totaled, this review led to 250+ recommended actions items. Sixty percent were implemented, according to the study, which led to documented systemic change within the ICU.

The hospital took the effort to identify potential causes of preventable ICU deaths and the appropriate steps to eradicate those causes. This method may not work for every hospital, but it shows that preventable deaths do occur, even in those patient populations with acute medical challenges.  There are concrete solutions and protocols hospitals should adopt to limit such unnecessary tragedies.

If you had a loved one die during a hospital stay, and you suspect an error in care was made, turn to a medical malpractice attorney to investigate.

The choice of a lawyer is an important decision that should not be based solely on advertisements.

Authored by Gray Ritter Graham, posted in Articles April 13, 2021