Errors detected by observation at the patient’s bedside, including medical record
| Category II audit questions* | Errors detected per 100 patient days† | Total no of errors |
|---|---|---|
| ETT, endotracheal tube; CVC, central venous catheter. | ||
| *Category II items: median number of patients audited for a given question = 58; average number of patients audited for a given question = 63; range of number of patients audited for a given question = 22–158. | ||
| †To calculate the number of errors per 100 patient days we divided the number of errors detected by the number of patients evaluated. This number was multiplied by 100. A patient was evaluated only if at risk for a given error; for example, only patients on a ventilator had ventilator alarms evaluated. | ||
| Hospital or unit policies and guidelines | ||
| Ventilator alarms not set at safe appropriate levels | 10.3 | 3 |
| ETT placement not confirmed on x ray (T2–3) | 6.9 | 2 |
| Cardiovascular alarms not set at safe appropriate levels | 11.9 | 8 |
| Intermittent suction not set to ⩽80 | 10.9 | 17 |
| Continuous suction not set to ⩽40 | 21.6 | 8 |
| Patient’s identification band not on the patient per hospital policy | 91 | 70 |
| Hand hygiene not practiced during multidisciplinary rounds | 61 | 48 |
| Distal ends of all tubes not labeled clearly | 42.4 | 61 |
| IV tubing being used is engineered to prevent enteral solutions frombeing given IV | 0 | 0 |
| Are there unlabelled or not clearly labeled syringes or med bagsat bedside? | 11.8 | 31 |
| CVC tip placement not confirmed by x ray on placement | 11.8 | 4 |
| 24 hour order check not done by nursing | 13.8 | 8 |
| Known safe practices | ||
| Pulse oximeter limits not set at safe appropriate levels (<32 weekscorrected gestational age, on supplemental O2 with high saturationlimit ⩾98%; ⩾32 weeks corrected gestational age, without pulmonaryhypertension, on supplemental O2 with high saturation limit 100%) | 47 | 22 |
| Alarms not set to 10 db above ambient noise | 57.8 | 21 |
| Total no of errors detected | 303 | |