Critical incidents in the intensive therapy unit

Lancet. 1991 Sep 14;338(8768):676-8. doi: 10.1016/0140-6736(91)91243-n.


Preventable mishaps in an intensive therapy unit were studied over 12 months by the critical incident technique. Staff were encouraged to complete confidential questionnaires describing incidents in which they had participated or had observed. This allowed classification of the events and examination of the views of staff on causes, detection, and prevention. 110 (80%) of 137 events were felt to have been due to human error; the remainder were due to equipment failure. Inexperience with equipment and shortage of trained staff were the factors most often felt to contribute to incidents. The critical incident technique is a useful way of improving standards of clinical care.

Publication types

  • Case Reports

MeSH terms

  • Accident Prevention*
  • Aged
  • Attitude of Health Personnel
  • Catheters, Indwelling
  • Critical Care / standards*
  • Equipment Failure
  • Evaluation Studies as Topic
  • Humans
  • Infusion Pumps
  • Intensive Care Units / standards*
  • Male
  • Middle Aged
  • Surveys and Questionnaires
  • Ventilators, Mechanical