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

Simon Andrew Hendel; Brendan Thomas Flanagan

doi:10.1177/0310057X0903700501

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

Simon Andrew Hendel, Brendan Thomas Flanagan

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3 Citations (Scopus)

Abstract

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 language	English
Pages (from-to)	847-850
Number of pages	4
Journal	Anaesthesia and Intensive Care
Volume	37
Issue number	5
DOIs	https://doi.org/10.1177/0310057X0903700501
Publication status	Published - 2009
Externally published	Yes

Access to Document

10.1177/0310057X0903700501

Cite this

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title = "Communication failure in the intensive care unit - Learning from a near miss",

abstract = "A 51-year-old female patient with Guillain-Barr{\'e} 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.",

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AU - Flanagan, Brendan Thomas

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AB - 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.

U2 - 10.1177/0310057X0903700501

DO - 10.1177/0310057X0903700501

M3 - Article

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JO - Anaesthesia and Intensive Care

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