Abstract
Medical error is thought to contribute to a significant proportion of adverse events in hospitalized patients. An adverse event is an injury caused by medical management rather than the underlying condition of the patient [1]. Three sentinel studies which have examined adverse events in hospitalized patients include those of Leape et al., Bates et al. and Thomas et al. [2]–[4]. The data on adverse events rates and preventable adverse events are detailed in Table 1.
This is a preview of subscription content, log in via an institution to check access.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Kohn L, Corrigan JM, Donaldson MS (2000) To Err is Human: Building a safer health system. Institute of Medicine, Washington, DC, National Academy Press
Leape LL, Brennan TA, Laird N, et al (1991) The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 324:377–384
Bates DW, Cullen DJ, Laird N, et al (1995) Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA 274:29–34
Thomas EJ, Studdert DM, Runcimen WB, et al (2000) A comparison of iatrogenic injury studies in Australia and the USA I: context methods casemix, population patient and hospital characteristics. Int J Qual Health Care 12:371–378
Safren MA, Chapanis A (1960) A critical incident study of hospital medication errors. Hospitals 34:32–34
Ollivier V, Thelcide C, Simon C, Favier M (2004) Standardized order form for investigational drugs: effect on completeness of the prescription. Pharm World Sci 26:178–179
Sutcliffe KM, Lewton E, Rosenthal MM (2004) Communication failures: an insidious contributor to medical mishaps. Acad Med 79:186–194
Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe ME (2002) Communication loads on clinical staff in the emergency department. Med J Aust 176:415–418
Murff HJ, Bates DW (2003) Information transfer. In: Shojania KG, Duncan BW, McDonald KM, Wachter RM (eds) Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment, No 74 Agency for Healthcare Research and Quality Publications. Available at: http://www.ahcpr.gov/clinic/ptsafety/chap42a.htm Accessed Nov 2005
Cook RI, Render M, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. BMJ 320:791–794
Donchin Y, Gopher D, Olin M, et al (1995) A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 23:294–300
Ash JS, Berg M, Coiera E (2004) Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. J Am Med Inform Assoc 11:104–112
Wears RL, Berg M (2005) Computer technology and clinical work: Still waiting for Godot. JAMA 293:1261–1263
Koppel R, Metlay JP, Cohen A, et al (2005) The role of computerised physician order entry systems in facilitating medication errors. JAMA 293:1197–1203
Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH (1994) Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med 121:866–872
Norgaard K, Ringsted C, Dolmans D (2004) Validation of a checklist to assess ward round performance in internal medicine. Med Educ 38:700–707
Lee LH, Levine JA, Schultz HJ (1996) Utility of a standardized sign-out card for new medical interns. J Gen Intern Med 11:753–755
Balas MC, Scott LD, Rogers AE (2004) The prevalence and nature of errors and near errors reported by hospital staff nurses. Appl Nurs Res 17:224–230
Roughton VJ, Severs MP (1996) The junior doctor handover: current practices and future expectations. J R Coll Physicians Lond 30:213–214
Bomba DT, Prakash R (2005) A description of handover processes in an Australian public hospital. Aust Health Rev 29:68–79
O’Connell B, Penney W (2001) Challenging the handover ritual. Recommendations for research and practice. Collegian 8:14–18
Kennedy J (1999) An evaluation of non-verbal handover. Prof Nurse 14:391–394
Leonard M, Graham S, Bonacum D (2004) The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care 13(suppl 1):85–90
Sexton JB, Thomas EJ, Helmreich RL (2000) Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ 320:745–749
Flin R, Fletcher G, McGeorge P, Sutherland A, Patey R (2003) Anaesthetists’ attitudes to teamwork and safety. Anaesthesia 58:233–242
Azuma T, Williams EJ, Davie JE (2004) Paws + cause = pause? Memory load and memory blends in homophone recognition. Psychon Bull Rev 11:723–728
Wright MC, Taekman JM, Endsley MR (2004) Objective measures of situation awareness in a simulated medical environment. Qual Saf Health Care 13(suppl 1):i65–71
Wiegmann DA, Shappell SA (1999) Human error and crew resource management failures in Naval aviation mishaps: a review of U.S. Naval Safety Center data, 1990–96. Aviat Space Environ Med 70:1147–1151
Helmreich RL, Wilhelm JA, Gregorich SE, Chidester TR (1990) Preliminary results from the evaluation of cockpit resource management training: performance ratings of flight crews. Aviat Space Environ Med 61:576–579
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH (1992) Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63:763–770
Risser DT, Rice MM, Salisbury ML, Simon R, Jay GD, Berns SD (1999) The potential for improved teamwork to reduce medical errors in the emergency department. The MedTeams Research Consortium. Ann Emerg Med 34:373–383
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2006 Springer Science + Business Media Inc.
About this paper
Cite this paper
Venkatesh, B., Miller, A., Karnik, A. (2006). Information Exchange in Intensive Care: How can we Improve?. In: Vincent, JL. (eds) Intensive Care Medicine. Springer, New York, NY. https://doi.org/10.1007/0-387-35096-9_71
Download citation
DOI: https://doi.org/10.1007/0-387-35096-9_71
Publisher Name: Springer, New York, NY
Print ISBN: 978-0-387-30156-3
Online ISBN: 978-0-387-35096-7
eBook Packages: MedicineMedicine (R0)