A look into the nature and causes of human errors in the intensive care unit

Abstract

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...

An analysis of near misses identified by anesthesia providers in the intensive care unit

“…The results of our study differ from the results of previous studies, supporting our hypothesis that anesthesia providers can highlight systems weaknesses and causal mechanisms in the ICU not identified by other personnel. As compared to previous work on critical incidents in the ICU by Donchin, et al , a larger proportion of near misses from our study occurred at night or on the weekend, [14] which could imply that decreased staffing in the ICU on off-hours impacts the ability of critical care providers to recognize, react to, and report near misses and adverse events. Additionally, the rate of technical errors in the ICU in our study was lower than previous estimates, [9] which was somewhat surprising given the technical role of the anesthesiologist in airway management and resuscitation.…”

Documentation of Incident Reports by Jordanian Nurses in Accredited Private Hospitals: Types and Causes

“…Results in Table number (15) shows that all of the three Jordanian accredited private hospitals were consistent in ranking the five causes of incidents and to choose the Insufficient /Improper use of equipments as the most leading cause while Insufficient number of staffing as the least leading cause of incidents but with different percentages .…”

Radiology department, human factors and organizational perspectives: using action research to improve patient safety

“…Referring a patient to a medical procedure without the information required reflects inadequate pattern communication that characterizes the complex health system. Previous studies [16,17] found that poor communication is a major cause of human errors in medical systems, and 50% of human errors reported by medical staff persons were caused by failures in transferring medical information [16]. These cause delays in providing medical treatment and may be the main obstacle to human errors prevention in medical care systems.…”

“…Standardization and homogeneous work procedures are essential because they structure the medical work environment, and enable the prediction of events during medical procedure performance [18]. In a study [17] that examined the nature of human errors in intensive care units, one of the major findings was lack of standardization - tubes, fluid bags, and drugs were insufficiently marked during performing the medical procedures. The researchers found that these problems caused staff members to improvise and develop their own style of working.…”

“…They noted that during a typical patient-physician encounter, physicians make nuanced choices regarding the words, questions, silences, tones, and facial expressions they use and that these can affect the overall quality of care delivered to the patient. Effective communication in transfer of medical information from the releasing department to the hospitalizing department should also be maintained between different caregivers, as it contributes to a complete, coherent and updated knowledge base of the patient status [17]. …”