QSEN 2

SLIP (execution error)

1) Accidentally pushing the wrong button 2) She drives through a gated entry point. 3) The doctor mistakenly enters John to the gastrointestinal (GI) lab for a colonoscopy.

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An unsafe act : an error or a violation committed, potential hazard An unsafe acts : errors or violations. Errors may be further categorized as slips, lapses, and mistakes.

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By focusing on the individual as the cause of error, organizations isolate individual unsafe acts from the system context, which includes a multitude of complex processes, in which they occur. As a result, the pursuit of greater patient safety is seriously impeded by an approach that does not seek out and remove the error-provoking properties within the larger system of care. In other words, the health care profession's traditional approach to fixing medical error is not valid anymore, if ever it was. There is another, more effective way to prevent unsafe acts in health care. By focusing more on the conditions under which individual providers and care teams work, and by designing in workflow and defenses to avoid errors, health care organizations can minimize the conditions that lend themselves to violations and put mechanisms in place to mitigate unsafe acts that may nevertheless occur. This "systems approach" can be quite successful in preventing medical error and making patients safe.

VIOLATION

Deliberate deviation from an operating rules Although deliberate, violations are not deviant behavior — "I know this is wrong, but I am going to do it anyway!" 1) The physician ignores the alert without reviewing the patient's medical record 2) Since she is busy, the nurse does not bring the patient's medical record into the room with her as required by policy

Human Error

Human error in health care — slips, lapses, and mistakes — has the potential to harm patients, depending on the nature of the error. For example, you may "slip" and push an incorrect button that gives the patient an overdose of medication. Likewise, you could have a "lapse" in memory, which causes you to give an incorrect dose of a life-saving medication. You may make a "mistake" and misdiagnose a patient, giving him or her treatment that supports the misdiagnosis and leads to severe harm. Violations can also lead to patient harm. Consider the nurse who is working with a medication bar coding system that repeatedly breaks down. One day she is rushing to give a patient his medication and she skips using the bar coding system — figuring it's probably broken anyway. Although not intending to, she is putting the patient at risk.

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In his book Human Error, James Reason said that errors can be divided into two types of failures: 1.An action does not go as intended. 2.An action goes as intended, but it's the wrong one. The first type of failure, in which an action does not go as intended, is a so-called error of execution and may be further described as being either a slip — if the action is observable — or a lapse, if it is not. An example of a slip is accidentally pushing the wrong button on a piece of equipment — you and others can see that you pushed the wrong button. An example of a lapse is some form of memory failure, such as failing to administer a medication, forgetting to wash hands — no one can see your memory fail, so the error is not observable.

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Let's look at an example that shows all three types of error: slips, lapses, and mistakes. A pharmacist on her way to work commits a mistake by not adequately assessing the driving conditions on a wet and cold road, barely avoiding a car that was stopped at a light and skidding out of control on "black ice." As traffic begins to flow again at the light, the pharmacist experiences a lapse as, preoccupied with a family problem, she fails to recognize the light has turned green. She's startled when she hears another car honking its horn behind her. Pulling into her hospital's parking lot, she commits a slip when, distracted by her pager, she nearly drives through a gated entry point. Three errors and she hasn't even prepared her first medication of the day!

LAPSE (execution error)

Memory failure (oops, I forgot to...) 1) Failing to administer a medication 2) Forgetting to wash hands 2) She fails to recognize the light has turned green 3) She gives an incorrect dose of a medication 4) He forgets to double check a critical reading 5) he forgot.... It turns out that the physician had been up for 24 hours performing surgeries and simply forgot. That was the first lapse. The female nurse, who offered to remove the patient's Foley catheter and vaginal sponge for her male colleague, got interrupted in the process and remembered to remove the Foley catheter but not the sponge. This was the second lapse. The male nurse assigned to the patient assumed the female nurse had removed the sponge without actually verifying it. This was the third lapse.

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One example in which such a systems approach was used to reduce error is the World Health Organization Surgical Safety Checklist. This tool helps reduce the likelihood of wrong-site surgery and the morbidity and mortality that stems from it. A prospective study using the checklist showed the rate of death declined by almost 50 percent and the complication rate decreased by almost 40 percent.14 In this example, errors were not reduced by imploring doctors to pay more attention, or asking nurses to slow down, or urging surgical teams to make better decisions. It was through changes in systems, communication, and teamwork that improvement was realized. Fundamentally, if we view unsafe acts as consequences rather than causes that have their origins in "upstream" systemic factors, and not in the perversity of the human condition, we can establish effective countermeasures that, while unable to change the human condition itself, can both accommodate it and change the conditions under which humans work. With this point of view in mind, then, our focus shifts from blaming the individual to identifying systemic factors or conditions that may cause unsafe acts. IHI Open School courses Patient Safety 101 and Patient Safety 102 discuss the causes of unsafe acts and make suggestions on how to redesign systems to prevent errors and violations that can lead to patient harm.

Violations

Physician ignores the alert without reviewing the patient's medical record, thinking the alert is likely to be another "false alarm." Behind on his schedule, he chooses to override the alert and prescribe the ibuprofen. After taking the medication, the patient develops bleeding in her gastrointestinal tract and has to be admitted to the hospital. Before dispensing the medication, the pharmacist takes a quick look at the drug label, but mostly relies on the pharmacy storage location from which he pulls the drug and the first four letters of the drug's name to convince him he has the right medication for the patient. After taking the medication at home, the patient gets nauseated, calls the pharmacy, and returns the incorrect medication. Since she is busy, the nurse does not bring the patient's medical record into the room with her as required by policy, and she remembers the patient's IV dose as 1,000 cc/hr instead of 100 cc/hr

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The second type of failure, in which an action goes as intended but is the wrong one, involves a failure in planning. This category of error, in Reason's terminology, is known as a mistake. Here's one example of a mistake: Mistake = Misdiagnosis Misdiagnosis: during a physical exam, a physician detects a lump in the right breast of a young, female patient. He's convinced, based on the patient's age and family history, that the lump could not be cancerous. He tells the patient that she probably has fibrocystic breasts — a common, non-cancerous condition — and he fails to pursue a more definitive diagnosis. Later, it's discovered that the lump is in fact cancerous. In this situation, the physician's plan is clear, and his actions go exactly as he planned — but the plan is incorrect.

1

While these examples may happen in your personal life, the tendency for human beings to inadvertently engage in unsafe behaviors does not end when they report to work. In fact, most preventable medical harm to patients is caused by unsafe acts of the very practitioners

Autonomy

With a history grounded in autonomy and individual culpability, and a culture that has equated unsafe acts with incompetence, you might guess that the predominant response in medicine following an incident of patient harm is to target individuals on the front lines of care — the doctors, nurses, pharmacists, and other people providing care to patients every day. Within this response, countermeasures are directed mainly at reducing unwanted variability in the individual provider's behavior. Countermeasures that have become the norm in medicine include poster campaigns that appeal to people's sense of fear, disciplinary measures, threats of litigation, retraining (using outdated and ineffective training methods), naming, blaming, and shaming. However, statistics from around the world show that errors are still occurring in health care at an alarming rate (see Lesson 1). By focusing on the individual as the cause of error, organizations isolate individual unsafe acts from the system context, which includes a multitude of complex processes, in which they occur. As a result, the pursuit of greater patient safety is seriously impeded by an approach that does not seek out and remove the error-provoking properties within the larger system of care.

MISTAKE (planning error)

action goes as intended but is the wrong one Mistake = Misdiagnosis, not assessing correctly, over-prescribing medication based on assessment 1) During a physical exam, a physician detects a lump in the right breast of a young, female patient. He's convinced, based on the patient's age and family history, that the lump could not be cancerous. He tells the patient that she probably has fibrocystic breasts — a common, non-cancerous condition — and he fails to pursue a more definitive diagnosis. Later, it's discovered that the lump is in fact cancerous. 2) A pharmacist on her way to work commits a mistake by not adequately assessing the driving conditions on a wet and cold road, barely avoiding a car that was stopped at a light and skidding out of control on "black ice." 3) She misdiagnosed a patient, giving him or her treatment that supports the misdiagnosis and leads to severe harm. 4) Misdiagnosis from the doctor

VIOLATION

intentionally skips a step At the end of the day, a respiratory therapist is late for picking up his children at day care. Because he is in a hurry, he speeds up (instead of slowing down) at two yellow lights, averaging about seven miles per hour above the posted speed limits along his route. These are all examples of violations, where the therapist either didn't recognize the risk he was taking or felt the risk was justified. He is not a bad person, and he is not acting with conscious disregard for safety, but his actions are potentially unsafe. Nurse who is working with a medication bar coding system that repeatedly breaks down. One day she is rushing to give a patient his medication and she skips using the bar coding system — figuring it's probably broken anyway. Although not intending to, she is putting the patient at risk. A pilot skips part of a pre-flight checklist in the interest of getting the flight off on time