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  • More than two decades after a landmark Institute of Medicine report, preventable medical errors continue to plague our health care system, with the ICU having the highest prevalence of preventable harm.

  • Distinguishing preventable harm from inevitable harm and recognizing preventable errors are essential first steps in preventing morbidity in the ICU.

  • Building a culture of change and improvement helps facilitate the successful implementation of quality improvement initiatives.

  • Tools for the implementation of quality improvement initiatives in the ICU include checklists, bundles, alerts, nudges, default orders, and dashboards.

  • Analysis of adverse events through root cause analysis should provide effective recommendations and interventions to prevent repeated adverse events.

  • Successful implementation of quality and safety initiatives can help achieve equity and reduce disparities in patient outcomes.


Despite the focus on quality and safety over the past two decades, preventable medical errors continue to plague our health care system. Patient safety and quality improvement initially came to the forefront of health care with the publication of the report To Err Is Human by the Institute of Medicine (IOM) and guidance from major governmental organizations such as the World Health Organization, Center for Medicare and Medicaid Services, and the Agency for Healthcare Research and Quality.1,2 Since To Err Is Human was published, quality improvement has evolved from observational studies and patient-safety movements into a robust scientific field that includes clinical trials and implementation science methods to test and apply interventions to prevent morbidity within health systems.1

The IOM framework of health care quality is perhaps the most influential in guiding quality assessment.3 This framework lists the following six aims for a high-quality health care system: safe, effective, patient-centered, timely (ie, reduces harmful delays), efficient, and equitable. With the evolution of critical care medicine as a field, there has been substantial improvement in all of these processes as they relate to care in the intensive care unit (ICU).4 However, in a recent systematic review and meta-analysis of preventable patient harm across health care settings, the ICU was identified as having the highest pooled prevalence of preventable harm at 18% (95% confidence interval [CI] 12%-26%).5 In this chapter, we discuss the importance of building an ICU environment focused on quality, review strategies to reduce morbidity in the ICU, and describe how the implementation of these strategies can improve outcomes and reduce disparities for critically ill patients.

Preventable Harm Versus Inevitable Harm

A critical feature of patient safety initiatives is distinguishing preventable harm from inevitable harm. With inevitable harm, everything is done correctly yet a negative outcome still occurs6; however, health care institutions should still review cases attributed to inevitable harm to ensure that the harm was truly inevitable. Institutional quality and safety efforts are generally focused on reducing preventable harm. Before taking steps to reduce ...

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