title: A look into the nature and causes of human errors in the intensive care unit.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Concurrent incident study.
  
  
  METHODS
  Medical-surgical ICU of a university hospital.
  
  
  RESULTS
  Two types of data were collected: errors reported by physicians and nurses immediately after an error discovery; and activity profiles based on 24-hr 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 the 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.
authors.affiliation: Department of Anesthesiology and Critical Care, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Y
authors.initials: Y
authors.lastname: Donchin
authors.forename: D
authors.initials: D
authors.lastname: Gopher
authors.forename: M
authors.initials: M
authors.lastname: Olin
authors.forename: Y
authors.initials: Y
authors.lastname: Badihi
authors.forename: M
authors.initials: M
authors.lastname: Biesky
authors.forename: C L
authors.initials: CL
authors.lastname: Sprung
authors.forename: R
authors.initials: R
authors.lastname: Pizov
authors.forename: S
authors.initials: S
authors.lastname: Cotev
mesh_terms: D006804:Ergonomics; D006801:Humans; D007049:Iatrogenic Disease; D007362:Intensive Care Units; D007400:Interprofessional Relations; D009726:Nurses; D010820:Physicians; D011446:Prospective Studies; D013647:Task Performance and Analysis