In a study that could have been sponsored by a smart pump vendor, researchers investigated the incidence of iatrogenic
injuries that occur in an intensive care unit. This was a one year
observational study in an academic tertiary care hospital. The findings
nonpreventable and 54 (45%) preventable adverse events as well as 223
serious errors. The rates per 1000 patient-days for all adverse events,
preventable adverse events, and serious errors were 80.5, 36.2, and
149.7, respectively. Among adverse events, 13% (16/120) were
life-threatening or fatal; and among serious errors, 11% (24/223) were
potentially life-threatening. Most serious medical errors occurred
during the ordering or execution of treatments, especially medications
(61%; 170/277). Performance level failures were most commonly slips and
lapses (53%; 148/277), rather than rule-based or knowledge-based
Failure to carry out intended treatment correctly was the leading category of error. This study was sponsored by HHS' Agency for Healthcare Research and Quality.
Too bad this (and virtually all) government funded studies are only
available for $$$ through online journals. It's almost like paying
twice, once with taxes and again to the publisher.