Fragmentation of treatment and the potential for human error in neonatal intensive care.

Neonatal intensive care involves continuous monitoring of highly unstable patients in order to plan and deliver effective care and treatment. Making care and treatment decisions depends upon using information obtained in many different ways. Analysis of care and treatment tasks shows how much staff need to rely on one another for crucial information. This problem becomes more acute as personnel change shifts, yet are still obliged to maintain continuity of care. Effective sharing of information is done through the medium of shared records, shift handovers, ward rounds, and informal verbal exchanges. This article describes strategies for understanding the tasks involved in neonatal intensive care, considers issues of task fragmentation, identifies the communication systems designed to minimize the effects of this fragmentation, and reviews problems associated with those systems that give rise to the potential for human error.