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Human error occurs in all walks of life, including medicine. Numerous studies demonstrate that iatrogenic complications account for many deaths, long-term disabilities and unnecessary expense. The study of these adverse events can be formalized in various ways in order to minimise the frequency and severity of complications. Incident monitoring borrows its methodology from the well proven airline, scuba diving and similar fields where "near miss" events are treated as seriously as actual events, because the near miss is often a pointer to a systematic problem which should be corrected. The areas of human performance psychology and the analysis of complex systems are of increasing relevance to the avoidance of error. These techniques have been incorporated into the Australian Incident Monitoring Program which developed in the anaesthetic forum but which has now been taken up by intensive care units and indeed hospital wide in many parts of Australia and New Zealand.

The AIMS-ICU project is a national study set up to develop, introduce and evaluate an anonymous voluntary incident reporting system for intensive care. ICU staff members reported events which could have reduced, or did reduce, the safety margin for the patient. Seven ICUs contributed 536 reports, which identified 610 incidents involving the airway (20%), procedures (23%), drugs (28%), patient environment (21%), and ICU management (9%). Incidents were detected most frequently by rechecking the patient or the equipment, or by prior experience. No ill effects or only minor ones were experienced by most patients (short-term 76%, long-term 92%) as a result of the incident. Multiple contributing factors were identified, 33% system-based and 66% human factor-based. Incident monitoring promises to be a useful technique for improving patient safety in the ICU, when sufficient data have been collected to allow analysis of sets of incidents in defined "clinical situations".

Intensive care units are complex, dynamic patient management environments. Incidents and accidents can be caused by human error, by problems inherent in complex systems, or by a combination of these. Study objectives were to develop and evaluate an incident reporting system. A report form was designed eliciting a description of the incident, contextual information and contributing factors. Staff group sessions using open-ended questions, observations in the workplace and a review of earlier narratives were used to develop the report form. Three intensive care units participated in a two-month evaluation study. Feedback questionnaires were used to assess staff attitudes and understanding, project design and organization. These demonstrated a positive attitude and good understanding by more than 90% participants. Errors in communication, technique, problem recognition and charting were the predisposing factors most commonly chosen in the 128 incidents reported. It was concluded that incident monitoring may be a suitable technique for improving patient safety in intensive care.

This prospective, observational, anonymous incident reporting study aimed to identify and correct factors leading to reduced patient safety in intensive care. An incident was any event which caused or had the potential to cause harm to the patient, but included problems in policy or procedure. Reports were discussed at monthly meetings. Of 390 incidents, 106 occasioned "actual" harm and 284 "potential" harm. There was one death, 86 severe complications and 88 complications of minor severity. Most were transient but the effects of 24 lasted up to a week. Most incidents affected cardiovascular and respiratory systems. Incident categories involved drugs, equipment, management or procedures. Incident causes were knowledge-based, rule-based, technical, slip/lapse, no error or unclassifiable. The study has identified some human and equipment performance problems in our intensive care unit. Correction of these should lead to a reduction in the future incidence of those events and hence an increased level of patient safety.

Pseudohypertension has been reported in elderly, diabetic and uraemic patients. A variety of diagnostic methods have been used, generally with poor results with the exception of arterial catheterisation. We report a case of pseudohypertension that developed in the year following a renal transplant and was diagnosed by the use of oscillometric and photoplethysmographic blood pressure measurement.

The intracellular to extracellular sodium distribution is one of the primary determinants of action potentials necessary for the electrical function of organs such as brain, heart and skeletal muscle. The ability of shift reagent enhanced 23Na MRS to directly measure the intracellular and extracellular sodium distribution in brain is controversial and centers on the relative contributions of bulk magnetic susceptibility and hyperfine interactions to the observed chemical shifts. In this study, infusion of dysprosium (III) triethylenetetraminehexacetate (Dy(TTHA)-3), resulted in a 23Na MRS spectrum of dog brain with two well resolved peaks at 9 and 0.4 ppm. The 9 ppm peak corresponded to the resonance seen in aspirated blood. After disruption of the blood brain barrier, the single peak at 0.4 ppm split into two peaks at 3 and 0 ppm. The ability of Dy(TTHA)-3 enhanced 23Na MRS to follow global changes in brain sodium distribution was tested during cardiac arrest. The expected rapid Na influx into the intracellular space produced a marked decrease in the 3 ppm signal and a parallel increase in the 0 ppm peak. This is consistent with the assignment of the 3 ppm peak as interstitial sodium and the 0 ppm peak as intracellular sodium.

In this article, we have reviewed the pathophysiology and several therapeutic strategies for cerebral ischemia. It seems likely that there will never be simple therapeutic answers to the complex pathophysiology of cerebral ischemia as we now understand it. Ultimate therapies will probably involve combinations of interventions designed to block several ongoing pathophysiologic processes in neuronal death. Progress in this field will likely be slow and difficult.

A case of fulminant hepatic failure, associated with infectious mononucleosis, in a previously healthy 14-year-old girl is reported. Despite intensive therapy, which included the use of acyclovir, charcoal haemoperfusion, and measures to control her raised intracranial pressure (guided by serial EEG and auditory brainstem-evoked response recordings), the outcome was fatal.

Hyponatremia, in patients with central nervous system disease, can be attributable to impaired free water excretion (syndrome of inappropriate secretion of antidiuretic hormone) or to excessive sodium excretion (cerebral salt wasting). We present a patient with a parietal glioma and hyponatremia characterized by salt wasting and dehydration. Rehydration and sodium repletion corrected the sodium and volume deficits; withdrawal of supplemental sodium resulted in recurrence of dehydration and hyponatremia. We determined sodium and water balance and measured plasma atriopeptin, antidiuretic hormone, and aldosterone. Plasma atriopeptin ranged from 8 to 44 pg/mL (normal, less than 45 pg/mL); antidiuretic hormone was not elevated at 4 to 5 pg/mL, and aldosterone was slightly elevated at 1040.25 pmol/L. The concentrations of these hormones could not directly explain the natriuresis; interactions with neural or other humoral factors may be involved. In evaluating such patients, careful attention to sodium and water balance is important to guide appropriate therapy.

Diarrhea is a common complication of enteral feeding in critically ill patients. This placebo-controlled clinical trial assessed the effect of adding fiber in the form of 'Fybogel' (Ispaghula husk), one sachet twice daily, on the occurrence of diarrhea during enteral feeding. Sixty-eight patients without prospectively defined exclusion criteria were enterally fed with 'Osmolite' in the Intensive Care Unit during the study period, 35 receiving 'Fybogel', and 33 placebo. Nineteen patients in each group had diarrhea on at least 1 day during enteral feeding, with 66 (23%) feeding days complicated by diarrhea in the 'Fybogel' group, and 68 (23%) in the placebo group. Narcotic infusions, thiopentone infusions, 'Mylanta', H2-antagonists, and nystatin suspension did not significantly affect the incidence of diarrhea. Weak correlations were found between diarrhea and the number of antibiotics each patient received (r = 0.2, p less than 0.05) and also the number of positive nonenteral bacterial cultures (r = 0.2, p less than 0.05). The addition of fiber in the form of 'Fybogel' to enteral feeds did not affect the occurrence of diarrhea.

A pressure infusor was used to apply external pressures of 300, 250, 200, and 150 mm Hg to 500-ml plastic bags of saline. At constant applied pressure, 50-ml aliquots of saline were periodically withdrawn. The delivered pressures were less than the applied pressures, and the difference increased as the volume of saline within the bag decreased. This inherent pressure difference should be considered when the system is used with a continuous flush device.

Venous thromboembolism to the heart is a rare and often fatal condition that is now being recognized more frequently owing to the widespread use of two-dimensional echocardiography. Death may be due to embolic obstruction of the tricuspid or the pulmonary valves, or to further migration of the embolus to the pulmonary arteries. The incidence of early recurrent pulmonary embolism is high. When used as primary treatment, medical treatment (anticoagulation or fibrinolytic therapy) failed in eight of 13 reported cases. Only one of eight patients died when surgical embolectomy was undertaken. We believe that an echocardiographic diagnosis of venous thromboembolism to the heart is sufficient evidence to warrant urgent surgical embolectomy. An undue delay in definitive treatment is often fatal.