Journal Article

Delayed recognition of deterioration of patients in general wards is mostly caused by human related monitoring failures: a root cause analysis of unplanned ICU admissions.

van Galen LS; Struik PW; Driesen BEJM; Merten H; Ludikhuize J; van der Spoel JI; Kramer MHH; Nanayakkara PWB.

Unplanned transfers of hospitalized patients to the intensive care unit are often considered a safety issue. This root cause analysis of consecutive unplanned intensive care unit admissions found that the most frequent cause was insufficient patient monitoring by nurses. In many cases, vital signs were not monitored as specified by treating physicians.