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 com...

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Veröffentlicht in:	Anaesthesia and intensive care 2009-09, Vol.37 (5), p.847-850
Hauptverfasser:	HENDEL, S. A, FLANAGAN, B. T
Format:	Artikel
Sprache:	eng
Schlagworte:	Anesthesia Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy Biological and medical sciences Care and treatment Case studies Communication Communicative disorders Diagnosis Dosage and administration Drug Overdose Female Guillain-Barre syndrome Guillain-Barre Syndrome - drug therapy Health aspects Humans Immunoglobulins Immunoglobulins - administration & dosage Intensive Care Units Medical Records Medical sciences Medication Errors - prevention & control Middle Aged Patient outcomes Risk factors Treatment Outcome
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Zusammenfassung:	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.
ISSN:	0310-057X 1448-0271
DOI:	10.1177/0310057x0903700501