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Qual Saf Health Care 12:143-147 doi:10.1136/qhc.12.2.143
  • Classic paper

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

  1. Y Donchin1,
  2. D Gopher2,
  3. M Olin2,
  4. Y Badihi2,
  5. M Biesky1,
  6. C L Sprung1,
  7. R Pizov1,
  8. S Cotev1
  1. 1Department of Anesthesiology and Critical Care, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
  2. 2Department of Human Engineering, the Technion, Israel Institute of Technology, Jerusalem, Israel

      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.

      Footnotes

      • This study was supported, in part, by a special grant from the Ministry of Labour and Social Affairs, The Committee for Research and Prevention in Occupational Safety and Health.

      • * This is a reprint of a paper that appeared in Critical Care Medicine, 1995, Volume 23, pages 294–300.

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