Understanding three types of human errors
Understanding three types of human errors
In talking about understanding the reasons for errors in the effort to support higher reliability, Marty B. Scott, MD, MBA, VP, quality and patient safety at Memorial Health University Medical Center in Savannah, GA, points to James Reason's swiss cheese model, proposed in 1990. Reason's model comprises four levels with each level illustrated as a piece of swiss cheese with holes. Multiple barriers are created to prevent errors from occurring and inherently each barrier can have its own weakness, or holes. When no barrier works to halt the error or recognize a problem, the error occurs, slipping right through the holes.
As an example, Scott offers this scenario. A non-pediatric pharmacist caring for a pediatric patient does not enter the patient's weight in the CPOE system and hand-calculates the dose. The admitting RN then does not independently calculate the dose per policy and is told by an experienced RN to override the smart pump alarm. Now two RNs are overriding the system put in place to catch errors, perhaps because of alert fatigue. The medication is then given incorrectly and you have a medication error. In this instance, the holes are lined up because no barriers caught the problem.
If you understand the ways humans make errors, Scott says, "you can design tools and techniques to try to minimize those errors or reduce those errors."
Skill-based errors, he says, are slips or lapses. On average, a person makes 25 to 30 errors in a normal day. One error might be leaving your car keys on the dining room table because you picked something else up, not realizing you don't have your keys until you get to your car.
"A rule-based error," he says, "has to do with our brain processes." When a situation occurs, "our brain goes back and looks in our mental file cabinet for similar situations that we've been in in the past and what was the correct response for those situations. In medicine, you make a up a differential diagnosis and then you try to work from your differential diagnosis. There are times you go in and select the wrong response from your experience file. Sometimes you may never have learned the correct response and so then you have to relearn the correct response. Or sometimes you may know the correct response... but decide that based on this situation, 'I need to do something different.'
"So there was a rule, there was a policy, but based on the particular needs of this patient or my interpretation of what was happening that day, I decided to do a work-around of that policy."
Knowledge-based errors are obviously due to lack of knowledge. But hopefully, Scott says, those don't reach the patient because you should have "pretty effective barriers." For instance, a medical resident can't write an order without a senior resident or attending co-signing it. Or if a physician realizes he needs information, he'll consult with the specialist who can provide that.
Skill- and rule-based errors, he says, can "oftentimes be prevented with a technique that's called STAR stop, think, act, review. For a skill-based error, what's been shown is that if you take about 10 seconds, stop what you're doing, think about what you're doing, you can eliminate skill-based errors." For example, if you're leaving home, stop at your door and take 10 seconds to think what do I have to have keys, cell phone, briefing documents and check those off in your mind.
With a rule-based error, it could be stopping for a minute before starting a procedure to think: Do I have the consent form correctly signed? Have I done the time out? Do I have everything I need?
"Those kind of internal behavior-based tools are what we use to try teach our teams... the point being is that with no more than a minute of stopping, thinking, acting, and reviewing, you could avoid a fair amount of problems."
In talking about understanding the reasons for errors in the effort to support higher reliability, Marty B. Scott, MD, MBA, VP, quality and patient safety at Memorial Health University Medical Center in Savannah, GA, points to James Reason's swiss cheese model, proposed in 1990.Subscribe Now for Access
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