Causes of near misses in critical care of neonates and children.
OBJECTIVE
The primary goal of this study was to examine the nature and causes of medical errors known as almost adverse events (AAEs) and potential adverse events (PAEs) in intensive care units.


METHODS
Observations were conducted in the Neonatal Intensive Care Unit and in the Pediatric Intensive Care Unit in a large hospital in Israel. The AAEs and PAEs were classified into three main categories: environmental, system and human factors. Data encoding and analysis was based on a Bayesian model previously developed to analyse causes of traffic accidents, and the categories were based on systems and ergonomics approaches.


RESULTS
'Workload' (a system factor) was the main cause of AAEs and 'communication failures' (a human factor) was the second main cause of AAEs. Among the environmental factors, 'failures in medical devices' was the most cited cause of AAEs. Environmental factors accounted for most of PAEs and among them 'form failures' was the most 'AAE'-prone factor.


CONCLUSIONS
Environmental factors (mainly 'failures in medical device') and system factors (mainly 'workload') accounted for most of AAEs in the intensive care units studied. The systems and the ergonomics approaches to error analysis can be useful in creating a comprehensive error management programme in order to minimize the gap between work demands and individual capabilities.
Tourgeman-Bashkin
O
O
Department of Industrial Engineering & Management, Ben Gurion University, Beer Sheva, Israel.
Shinar
D
D
Zmora
E
E
D001499:Bayes Theorem; D002648:Child; D003422:Critical Care; D004777:Environment; D006801:Humans; D007049:Iatrogenic Disease; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric / Q000592:standards; D015931:Intensive Care, Neonatal / Q000592:standards; D019300:Medical Errors