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Michal Bieski

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Publications by Michal Bieski (bibliography)

1989

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Gopher, Daniel, Olin, Miriam, Badihi, Yehuda, Cohen, Gilat, Donchin, Yoel, Bieski, Michal and Cotev, Shamay (1989): The Nature and Causes of Human Errors in a Medical Intensive Care Unit. In: Proceedings of the Human Factors Society 33rd Annual Meeting 1989. pp. 956-960.

“The article presents the main outcomes and conclusions of a two year research effort directed to study the causes of human errors in a Respiratory Intensive Care Unit (ICU). In the course of the study, doctors and nurses recorded errors in treatment routines that were committed during their daily work. Over a period of 4 months we collected 554 errors, which were independently judged for their criticality. In addition, 46 twenty-four hour observations were conducted of all activities at a patient bed. A total of 8178 activities were recorded over the 46 observations. We also performed a detailed human factors analysis of the patient bed as a work station. It was found that the dominant cause of error is problems related to complete and clear documentation and transfer of information between staff members. Additional causes were lack of standardization in equipment composition and layout, as well as absence of adequate marking and labeling. These problems seem to be equally relevant to other ICU's visited by the team. Remedial steps are presently being implemented.”

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