Although healthcare providers are not expected
to make errors, mistakes do occur, and some mistakes have resulted in serious injury or death. Each year, approximately 1.3 million patients are injured because of error during their hospitaliza- tion,and more than 100 000 deaths due to preventable adverse events occur. The effects of human error may be more significant for patients in critical care units (CCUs). These patients are not only exposed to more medications and treatments than are patients in general care areas but are also seriously ill, with little natural resilience or ability to defend themselves from the consequences of healthcare mishaps.