Letter to the editor SWISS MED WKLY 2001;131:166 · www.smw.ch 166

CI (critical incidents) vs. CI (corporate identity)

Michele Losa, Bernhard Frey, Karin Zimmermann Neonatal and paediatric ICU, Ostschweizer Kinderspital, St.Gallen, Switzerland

We previously described the critical inci- the incorrect storage. She reported the ob- health care providers (doctors, nurses), na- dent (CI) monitoring in our ICU [1]. Our servation on a critical incident monitoring tional drug control agencies and manufactu- model is based on confidential reporting of sheet. All reports are analysed by the CI group rers. We encourage all prescribers of drugs to critical incidents which could have reduced, (two nurses and one consultant) every 2 report observations likely to improve patient or did reduce, the safety margin for the pa- months. Since confusion of the two drugs, re- safety to their national medicine control tient: the model regards errors or deviations spectively for intravenous and intratracheal agencies and drug manufacturers. As in our not as human failures but as opportunities to use, could be harmful [2], the CI group con- case, health care authorities and drug suppli- improve the system (system approach). tacted the Swiss Intercantonal Office for the ers could play a constructive role in these ef- During a routine drug check, one of the Control of Medicines (IKS) which, in turn, forts. staff nurses (with board certification) found informed the manufacturer. Very shortly af- ® erythromycin (Erythrocin i.v.) (Fig. 1) in the terwards (4 months), the company changed Correspondence: ® place where surfactant (Survanta ) (Fig. 2) is the colour of the packaging for surfactant Dr. Michele Losa usually stored (in a high performance refrig- from red to blue (Fig. 3). Intensivstation erator). The nurse realised that both drugs This is an example of how our CI re- Ostschweizer Kinderspital were manufactured and distributed by the porting system works: through a change in the Claudiusstr. 6 same company (Abbott AG, Baar, Switzer- system we endeavour to ensure a wider safety CH-9006 St.Gallen land) and that the packaging was almost iden- margin for the patient. This report highlights E-mail: [email protected] tical, a fact which could have accounted for the importance of cooperation between

References 1 Frey B, Kehrer B, Losa M., Braun H, Berweger L, Micallef J, Ebenberger M. Comprehensive critical incident monitoring in a neonatal-pedi- atric intensive care unit: experience with the sys- tem approach. Intensive Care Med 2000;26: 69–74. 2 Frey B, Keller E, Losa M. Seizures after inadver- tent umbilical venous infusion of synthetic sur- factant (Exosurf): cause or coincidence? Eur J Pe- diatr 1999;158:610.

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