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Registry System for the Notification of Adverse Events Related To Mechanical Ventilation of Critically Ill Patients

Purpose: To search and describe adverse events associated with mechanical ventilation (MV) and artificial airway in the Intensive Care Unit.

Method: Prospective cohort study of the adverse events derived from MV or artificial airway, performed for 7 days (24/03/14 to 31/03/14) 24 h a day. Previous training sessions were held for medical and nursing staff; as well as the anonymous registration system was reviewed, for the proper coding. Adverse events were classified according to the World Health Organization following the degree of damage. The study was approved by the Centre’s Clinical Research Ethics Committee.

Results: A total of 25 patients on MV were detected, with a mean of 96.64 h on MV/per patient; 16 adverse events were registered. At least one incident occurred in 48% of cases. 75% of the events were harm-free, with the need for intervention/review in 18.7% of the episodes. The complexity of the patient was the main factor contribution. They were more frequent in the morning shift 62.5% and preventability was observed in 37.5% of the notifications.

Conclusion: In our study, half of the patients in the sample presented some adverse events related to MV in the study period, the majority without damage. There is an increase in the frequency of events in the shifts of greater assistance activity, with the MV being a highly complex support. The detection of adverse events, with the implementation of protocols and a notification system, is an essential tool in order to enhance the safety culture, it´s research and learning. In this process they can contribute to prevent the incidents, due to improve the safety of the critically ill patients.


ME Martínez Barrio, Carolina Saez Gavilán, Esther Portugal Rodríguez, Maria Gero Escapa, JA Fernández Ratero and Celia Diaz Tobajas

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