Errors in intensive care

BBC reports an international study, published in BMJ, showing that 4 out of 5 ITUs studied in a 24 hour period made errors in administering injected drugs, the most frequent being wrong timings or missed doses, but sometimes also incorrect doses or use of the wrong drug. Staff cited working under pressure and being over-tired as factors contributing to their errors, but changes in drug names, poor communication between staff and non-adherence to protocols also contributed. A suitable case for treatment by design of both products and systems.