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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Bibliographic Details
Published in:Anaesthesia and intensive care 2009-09, Vol.37 (5), p.847-850
Main Authors: HENDEL, S. A, FLANAGAN, B. T
Format: Article
Language:English
Subjects:
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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Summary: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