Communication failure in the intensive care unit--learning from a near miss.
A 51-year-old female patient with Guillain-Barré syndrome was given three times the intended dose of intravenous human immunoglobulin while admitted to a tertiary intensive care unit. The error went unnoticed for seven hours and appears to have been the result of several successive breakdowns in communication between key staff The patient, fortunately, made a full recovery. This report analyses the communication failure and explores possible ways of avoiding similar occurrences in the future.
Southern Health Simulation Centre, Melbourne, Victoria, Australia.
S A
SA
Hendel
B T
BT
Flanagan
D003142:Communication; D062787:Drug Overdose; D005260:Female; D020275:Guillain-Barre Syndrome / Q000188:drug therapy*; D006801:Humans; D007136:Immunoglobulins / Q000008:administration & dosage*; D007362:Intensive Care Units; D008499:Medical Records; D008508:Medication Errors / Q000517:prevention & control; D008875:Middle Aged; D016896:Treatment Outcome
D007136:Immunoglobulins