Study: Most Human Errors Stem From Medical Work Environment

The physical and mental workload of medical staff, faulty communication between medical teams, medical instrument malfunctions and the congestion of instruments near patients' beds are among the causes of human errors that could endanger the lives of premature babies and children in intensive care units.

Such is the conclusion of a study by the Health Ministry's National Institute of Health Policy into the reasons for grave medical occurences in these departments, and the ways in which to avoid them. It finds that the overwhelming majority of malfunctions - 91 percent of those found in pediatric intensive care units and 81 percent in neonatal intensive care units (NICU) - derive from problems in the medical team's work environment.

The study, consisting of 500 hours of observation, provides a glimpse behind the scenes of pediatric and neonatal intensive care units and documents malfunctions that could have cost human lives or incurred severe medical damage. It was conducted by the director of the Department of Neonatology in the Soroka Medical Center, Prof. Ehud Zmora, and Prof. David Shinar and Osnat Bashkin of the Department of Industrial Engineering and Management at Ben-Gurion University, two years ago.

Consisting of observations of 62 eight-hour shifts in the neonatal and pediatric departments in Soroka, the study lists 114 incidents of what it calls "almost medical errors."

"This consists of prescribing the wrong dose of medicine that was discovered in time, or almost giving the wrong infusion," Zmora said. The study lists 56 incidents of "potentially grave medical events." This includes the medical team's failure to notice or diagnose the signs indicating bodily changes on the instrume nts monitoring the preemies' breathing and blood pressure, he said.

The study finds that most "near blunders" - in 59 percent of the incidents - are caused by the doctors and nurses' "mental or physical workload."

Most "near blunders" took place during shift changes, as a result of an excess of medical tasks or contradictory tasks, the study states.

"Communication breakdowns" resulting from doctors' unintelligible handwriting or passing insufficient medical information about the sick preemies and children caused 37 percent of the incidents in the neonatal department and 20 percent of the incidents in the pediatric intensive care unit.

The study was intended to increase nurses and doctors' cooperation in reducing the number of errors during medical treatment.

Zmora and Shinar said that the medical team refrained from reporting medical blunders, for fear of medical negligence suits. This prevents the effective study of mistakes.

The study finds that the work environment and difficulty in filling out medical forms could also cause malfunctions. Old or broken medical equipment or not knowing how to operate new equipment caused 21 percent of the malfunctions.

The congestion of medical equipment close to the beds was responsible for 19 percent of recorded medical incidents.

"The study's findings have since been corroborated by a similar study conducted in 10 other neonatal departments in Israel," Zmora said.

"It was not possible to implement a large part of the study's findings in Soroka, due to the acute shortage of personnel," he said. "Since t he Health Ministry calls pediatric and neonatal intensive care units 'departments of special treatment,' it allocates them half the personnel earmarked for adult intensive care units."

The Health Ministry commented: "The 2006 budget allocated NIS 25 million for medical equipment for neonatal departments in hospitals. In addition, following the recommendations of a special committee for personnel shortage in neonatal departments, beginning with the 2006 budget, 25 nursing positions will be allocated annually in each of the next five years to the 11 state hospitals."