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Medical error and decision making : learning from the past and present in intensive care

journal contribution
posted on 2010-08-01, 00:00 authored by Tracey BucknallTracey Bucknall
Background : Human error occurs in every occupation. Medical errors may result in a near miss or an actual injury to a patient that has nothing to do with the underlying medical condition. Intensive care has one of the highest incidences of medical error and patient injury in any specialty medical area; thought to be related to the rapidly changing patient status and complex diagnoses and treatments.

Purpose :
The aims of this paper are to: (1) outline the definition, classifications and aetiology of medical error; (2) summarise key findings from the literature with a specific focus on errors arising from intensive care areas; and (3) conclude with an outline of approaches for analysing clinical information to determine adverse events and inform practice change in intensive care.

Data source : Database searches of articles and textbooks using keywords: medical error, patient safety, decision making and intensive care. Sociology and psychology literature cited therein.

Findings : Critically ill patients require numerous medications, multiple infusions and procedures. Although medical errors are often detected by clinicians at the bedside, organisational processes and systems may contribute to the problem. A systems approach is thought to provide greater insight into the contributory factors and potential solutions to avoid preventable adverse events.

Conclusion : It is recommended that a variety of clinical information and research techniques are used as a priority to prevent hospital acquired injuries and address patient safety concerns in intensive care.

History

Journal

Australian critical care

Volume

23

Issue

3

Pagination

150 - 156

Publisher

Elsevier

Location

Amsterdam, The Netherlands

ISSN

1036-7314

eISSN

1878-1721

Language

eng

Publication classification

C1 Refereed article in a scholarly journal

Copyright notice

2010, Australian College of Critical Care Nurses Ltd.