The Nature and Causes of Human Errors in a Medical Intensive Care Unit

Abstract

The articel presents the main outcomes and conclusions of a two year research effort directed to study the causes of human errors in a Respiratory Intensive Care Unit (ICU). In the course of the study, doctors and nurses recorded errors in treatment routines that were committed during their daily work. Over a period of 4 months we collected 554 errors, which were independently judged for their criticality. In addition, 46, twenty-four hour, observations were conducted, of all activities at a patient bed. A total of 8178 activities were recorded over the 46 observations. We also performed: a detailed human factors analysis of the patient bed as a work station. It was found that the dominant cause of errors are problems related to complete and clear documantation and transfer of information between staff members. Additional causes were lack of standatization in equipment composition and layout, as well as absence of adequate marking and labeling. These problems seems” to be equally relevant to other ICU's visited by the team. Remedial steps are presently being implemented.