Preventing human errors in healthcare

Human error is a determining factor in 70% to 80% of industrial accidents, as well as in a large percentage of errors and adverse events experienced in healthcare. In fact, it’s a commonly held belief in some healthcare settings that human error represents the root cause of many adverse events.

Human error in healthcare settings occurs because of several factors:

• The vast amount of new research and recommendations that are regularly released.  In 2010, a new journal article was published to the National Library of Medicine every 40 seconds, and it’s likely that rate has grown over the past few years. No healthcare provider, regardless of dedication, can find the time to keep current with the vast amount of new science that should influence care decisions.
• Clinical care is delivered as part of a complex-adaptive system that is composed of many tightly coupled microsystems.  Some safety gurus have proposed that errors will inevitably occur when care is delivered under such conditions. This conclusion is based upon the notion that modifications in one microsystem, typically made in the name of efficiency or good practice, will expose vulnerabilities in other microsystems that will compromise the delivery of safe care. 
• Human beings are highly susceptible to cognitive biases that adversely affect our ability to solve problems accurately and reliably. We also exhibit significant limitations in our working memory that make us prone to error due to factors such as distraction, stress and sleep deprivation.

Addressing the issue

MazzaHealthcare professionals clearly manifest the desire to prevent errors and adverse events, and to mitigate their effects when they occur. To do this, they must understand why these events transpired in the first place. 

In this regard, event-reporting systems are critical tools. They enable healthcare professionals to identify and catalogue the contributing factors that lead to incidents, and frequently detail with great accuracy why they occurred without the requirement of the time and expense of a more formal root-cause analysis.

When captured in a structured taxonomy, incidents can be aggregated and prioritized for performance improvement.  Because errors and adverse events occur relatively frequently in healthcare, no organization can afford to maintain resources that target them all for improvement at one time.  But organizations can efficiently and effectively learn and improve through prioritization of their efforts following review of their data. 

The majority of organizations target their most serious incidents for immediate attention. Events that lead to severe and/or permanent injury or death are typically underscored in an effort to prevent them from ever happening again. But recurrent errors that have the potential to do harm must also be prioritized for attention and process improvement.  After all, whether an incident ultimately results in a near miss or an event of harm leading to a patient’s death is frequently a matter of a provider’s thoughtful vigilance, the resilience of the human body in resisting catastrophic consequences from the event, or sheer luck.

Next: Must-have elements

Must-have elements

Ultimately, the ability of an organization to learn from errors and events, and to focus their efforts on recurring errors, depends upon judicious use of their event-reporting system.  This, in turn, requires that the system feature a number of critical attributes:

The incident-reporting system must be highly “usable.”  That is, it must be intuitively designed and allow for rapid capture of events (i.e., within two to five minutes).  Busy clinicians simply cannot and will not take the time to enter an event if that act requires them to deviate from direct patient care for an extended time.

Leadership in the organization must sponsor and model the “Just Culture.”  Just Culture is defined by the European Commission as “a culture in which front line operators or others are not punished for actions, omissions, or decisions taken by them that are commensurate with their experience and training, but where gross negligence, willful violations, and destructive acts are not tolerated.” If Just Culture is not promoted, front-line providers will resist sharing error details if they fear it will compromise their professional standing. 

Data must also be collected post incident. Data must be collected on the back-end to ensure that the improvements to the system that are introduced have been successfully integrated into the delivery of care and serve the purpose for which they were intended.  Without these three elements, the organization’s quest to deliver unfailingly safe care will very likely be unsuccessful.

Frank Mazza, MD, chief medical officer, Quantros, is a physician by training (pulmonary, critical care and sleep disorders), and still practices medicine part-time. Prior to joining Quantros, he held several executive positions within the Seton Healthcare Family in Austin, Texas, including system-level chief patient safety officer and associate chief medical officer, as well as vice president of medical affairs at Seton Medical Center, Austin.