Identification of Patient Safety Threats in a Post-Intensive Care Clinic : American Journal of Medical Quality

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Identification of Patient Safety Threats in a Post-Intensive Care Clinic

Karlic, Kevin J. MD1; Valley, Thomas S. MD, MSc2,3,4; Cagino, Leigh M. MD2; Prescott, Hallie C. MD, MSc2,3; Iwashyna, Theodore J. MD, PhD2,3; Mohammad, Rima A. PharmD5; Pitcher, Mari LMSW1; Haezebrouck, Evan PT, DPT6; McSparron, Jakob I. MD2

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American Journal of Medical Quality 38(3):p 117-121, May/June 2023. | DOI: 10.1097/JMQ.0000000000000118


The extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study conducted at an academic, tertiary care medical center used qualitative survey data analyzed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorized into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviors (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.

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