Learning from non-routine events and teamwork in intensive care units: challenges and opportunities.
Non-routine events (NRE), or deviations from optimal care, are latent safety threats, and their early identification and elimination can improve patient safety. This article uses an example of a medication error in the intensive care unit presented in a PSNet WebM&M case and commentary to describe NRE in the context of time-dependent tasks and teamwork, the use of real-world data to investigate them, and the challenges of identifying NRE.