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The Human Factors: Errors and Skills

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Crisis Management in Acute Care Settings

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Abstract

During an afternoon shift two hemodynamically unstable patients were admitted to the cardiac ICU (CCU), one immediately after the other. The physician’s attempt to stabilize both patients at the same time completely overwhelmed him. Because of this, he was unable to give adequate attention to a patient being anticoagulated with warfarin who had several episodes of coffee-ground emesis during the previous 2 h. After finally stabilizing the two new admissions, the resident prepared for an upper endoscopy, but the patient suddenly became hemodynamically unstable. The patient had a recent hemoglobin value of 6.9 g/dl. With the working diagnosis of acute upper gastrointestinal (GI) bleeding, the patient received several peripheral IV lines. Crystalloid infusions were started. Six units of cross-matched packed red blood cells (PRBCs) were ordered from the blood bank, which was short of personnel and unusually burdened by many orders for blood products.

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Editors and Affiliations

  1. Department of Anesthesiology, University of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany

    Michael St. Pierre

  2. Hohenheimerstrasse 104, 71686, Remseck, Germany

    Gesine Hofinger

  3. Woehlerstrasse 12, 10115, Berlin, Germany

    Cornelius Buerschaper

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© 2008 Springer-Verlag Berlin Heidelberg

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(2008). The Human Factors: Errors and Skills. In: St. Pierre, M., Hofinger, G., Buerschaper, C. (eds) Crisis Management in Acute Care Settings. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-71062-2_1

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  • DOI: https://doi.org/10.1007/978-3-540-71062-2_1

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-540-71061-5

  • Online ISBN: 978-3-540-71062-2

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