turn were clustered into four events4
: deterioration in
the patient’s condition, adverse event or near
incident, change in the nursing or medical plan and
introduction of new equipment.
Most problems addressed by the nurses relate to the
event deterioration in the patient’s condition (12
problems out of 22). Uncertainty about the cause of a
deterioration in the patient’s condition was
mentioned most often, followed by poor team
dynamics under time-critical circumstances, and
discord with patient and relatives or the responsible
medical specialist about the medical plan. Most
issues addressed by the managers relate to the events
deterioration in the patient’s condition and adverse
event or near incident. Discord about the medical
policy with patient and relatives is mentioned most
often by this group (e.g., a 14-year old patient
transferred to the nursing ward, while his parents
want him to stay in the ICU). Problems that relate to
learning were mentioned by the ICU managers only.
The nurses did not mention any problems in relation
to learning.