Communication failure in the intensive care unit--learning from a near miss
Autor(es): Hendel S A,Flanagan B T
Resumo: 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.
Imprenta: Anaesthesia and Intensive Care, v. 37, n. 5, p. 847-850, 2009
Descritores: Guillain-Barre Syndrome - Proteins ; Guillain-Barre Syndrome - Public health
Data de publicação: 2009