Human Errors in Intensive Care

This report investigates the nature and causes of human errors within intensive care units (ICUs). The strengths of the study highlight the crucial role of nurses in continuous patient monitoring, bridging communication gaps between nurses and physicians, and defining distinct roles for each profession. Weaknesses identified include communication issues, particularly during shift changes and emergencies, leading to delays and misinterpretations. The report emphasizes the need for improved communication protocols, standardized procedures, and better access to patient information. Applications of the findings focus on reducing error rates through human factors engineering, improved task design, and better workplace organization. The study also underscores the importance of clear labeling, reduced congestion around patient beds, and improved verbal communication between nurses and physicians. The report concludes by discussing techniques for calibrating and qualifying error reports for medical staff.

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A look into the nature and causes of human errors in the intensive care unit
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A look into the nature and causes of human errors in the intensive care unit
Strengths: The findings of the paper present a crucial importance to the paper in case of
intensive medical care. In an intensive medical care it was seen that the nurses are involved in
much more continuous monitoring of each and every patient as compared to the physicians. They
can act like an active liaison and help the physicians in avoiding confusion gaps along with
bridging information gaps. The findings suggests the important role of nurses in the intensive
medical care. Further, they are seen to provide a suitable communication and exchange pattern
enabling the patients and residents to gain from it. The findings suggested a clear difference
between the nature of the tasks performed by the nurses and physicians. Their role have been
successfully defined by placing the roles of nurses around the routine and repetitive activities
whereas the activities of the physicians are comprised of the initiated as well as reactive
interventions.
Weakness: The issues in the study include the problems in the exchange of information. There
were issues encountered in the verbal communications and only a few number of nurses and
physicians were seen to confer with each other in the activities. It was seen that nurses were not
included in the physicians’ rounds leading to errors in diurnal distribution especially in the
morning houses. It was seen that approximately 1 hour delay was seen due to nurses and the
possibility of errors increased during the shift change leading to further issues in the information
exchange. The probability of errors increased during the information exchange in the emergency
conditions. As the exchanges were misunderstood and misperceived most of the times. Therefore
there is need to establish formal briefing procedures among the staff member of the intensive
medical care. Further the findings depicted the issues like complicated access to the patient’s and

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issues with status and identification assessment. There were problems in reading the labels of
drugs, tubes, fluid bags etc. and congestion around the bed of the patient.
Application: There is a need to reduce the error rate and provisions must be made to change the
behaviour of staff members. The findings will help in improving the task requirements,
technology and ability of workers to match up with the demands of the tasks. The findings
helped to focus on the advantages of the human factors engineering approach. The findings also
focussed on the importance of standardization and low congestion of the wires, monitors,
instruments and intravenous catheters revolving around the bed of the patient. It help in focusing
on the nurses and physicians interaction and will also place a great importance to the verbal
communication among them. The paper discussed on the techniques that served as a great
support for calibration and qualification of the error reports for the use of medical staff.

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References
Donchin, Y., Gopher, D., Olin, M., Badihi, Y., Biesky, M., Sprung, C. L., ... & Cotev, S. (2003).
A look into the nature and causes of human errors in the intensive care unit. Quality and Safety
in Health Care, 12(2), 143-147.