Communication failure in the intensive care unit - Learning from a near miss

Simon Andrew Hendel, Brendan Thomas Flanagan

Research output: Contribution to journalArticleOther

3 Citations (Scopus)


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.
Original languageEnglish
Pages (from-to)847-850
Number of pages4
JournalAnaesthesia and Intensive Care
Issue number5
Publication statusPublished - 2009
Externally publishedYes

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