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

Publication ,  Journal Article
Pronovost, PJ; Wu, AW; Sexton, JB
Published in: Ann Intern Med
June 15, 2004

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.

Duke Scholars

Published In

Ann Intern Med

DOI

EISSN

1539-3704

Publication Date

June 15, 2004

Volume

140

Issue

12

Start / End Page

1025 / 1033

Location

United States

Related Subject Headings

  • Renal Insufficiency
  • Renal Dialysis
  • Posture
  • Patient Care Team
  • Neoplasm Metastasis
  • Middle Aged
  • Medical Errors
  • Hypoxia-Ischemia, Brain
  • Humans
  • Heart Failure
 

Citation

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Pronovost, P. J., Wu, A. W., & Sexton, J. B. (2004). Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med, 140(12), 1025–1033. https://doi.org/10.7326/0003-4819-140-12-200406150-00013
Pronovost, Peter J., Albert W. Wu, and J Bryan Sexton. “Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit.Ann Intern Med 140, no. 12 (June 15, 2004): 1025–33. https://doi.org/10.7326/0003-4819-140-12-200406150-00013.
Pronovost, Peter J., et al. “Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit.Ann Intern Med, vol. 140, no. 12, June 2004, pp. 1025–33. Pubmed, doi:10.7326/0003-4819-140-12-200406150-00013.
Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004 Jun 15;140(12):1025–1033.

Published In

Ann Intern Med

DOI

EISSN

1539-3704

Publication Date

June 15, 2004

Volume

140

Issue

12

Start / End Page

1025 / 1033

Location

United States

Related Subject Headings

  • Renal Insufficiency
  • Renal Dialysis
  • Posture
  • Patient Care Team
  • Neoplasm Metastasis
  • Middle Aged
  • Medical Errors
  • Hypoxia-Ischemia, Brain
  • Humans
  • Heart Failure