Objectives: The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered. Design: Concurrent incident study. Setting: Medical-surgical ICU of a university hospital. Measurements and main results: Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-h records taken by observers with human engineering experience on a sample of patients. During the 4 months of data collection, a total of 554 human errors were reported by the medical staff. Errors were rated for severity and classified according to the body system and type of medical activity involved. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. For the ICU as a whole, a severe or potentially detrimental error occurred on average twice a day. Physicians and nurses were about equal contributors to the number of errors, although nurses had many more activities per day. Conclusions: A significant number of dangerous human errors occur in the ICU. Many of these errors could be attributed to problems of communication between the physicians and nurses. Applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors. Errors should not be considered as an incurable disease, but rather as preventable phenomena.I nvestigations of the nature of human errors in hospitals are rare. It is human nature not to report errors, and the medical profession is no different from other professions. The importance of error prevention was recognized by anesthesiologists with the publication of error analysis and critical incidences in the operating theater. 1 (Anesthesiology is one of the few fields to publish such a study.) The paucity of published investigation in this area may be related, at least in part, to the fear of legal liability.Great efforts have been invested in the industrial sector in the analysis of job requirements and the design of workplaces, equipment, and the physical environment for the benefit of workers. In air traffic control, for instance, human factors have been studied extensively. 2 In contrast, almost no attention has been given to human factor considerations in the hospital setting. As malpractice premiums have increased, hospitals tend to spend more time preparing themselves against liability claims rather than actively trying to avoid errors. A recent review 3 concluded that "reducing the incidence of the events will require identification of their causes and developing methods to prevent errors or reduce their effect".Observations during routine daily activities in the intensive care unit (ICU) demonstrated that mistakes do occur, sometimes with severe consequences. 4 5 The present prospective study investigated the nature and c...

Ein -Karem, Jerusalem.The articel presents the main outcomes and conclusions of a two year research sffort directed to study the causes of human errors in a ReaniratoryIntensive Care Unit (ICU). In the course o f the study, doctors and nurses recorded errors in treatment routines that were committed during their daily work. Over a period of 4 months w e collected 554 errors, which were independently judged for their criticality. In addition, 4 8 . twentyfour hour, observations were conducted, of all activities at a patient bed.A total o f 8178 activities were recorded over the 46 observations. W e also performed a detailed human factors analysis of the patient bed as a work station.' I t w a s 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 i n equipment composition and layout, as well as absence o f adequate marking and labeling. These problems s e e m s : t o be equally relevant to other ICU's visited by the team. Remedial steps are presently being implemented.