O context What moves us determines both our results and our will and dedication. But we feel the weight of responsibility as if everything depended exclusively on us. It is a characteristic of our individualistic culture and understanding the context will help us improve healthcare assistance.
In Patient Safety, healthcare professionals improve their performance by understanding their relationship with the context.
The operation of a hospital is a complex or socio-complex system, due to the high dependence on people's skills to operate the processes.
Complex systems have a non-linear relationship between causes and effects. We have several factors that act on a result that affects other factors. (read more at “Organizational Culture”). We have relationships that are fed back positively or negatively.
Humans tend to look for a linear causal relationship and to think serially (one problem after another). We usually do not see the whole field, only the part that corresponds to us, so paradoxical (unexpected) results appear.
In this context, with limited resources, incomplete information, pressure on production delivery, fatigue and performing several tasks at the same time (multitasking) we have to deliver results without errors or violations, which seems like an unequal fight.
Most studies of accidents or adverse events focus on human error as the triggering cause of disasters. We rarely see professionals as heroes. However, it is often these professionals who correct 100 problems and only make one mistake.
We are not proposing to break the rules, but to understand the cause, the reason why many rules are broken. Some are broken because it is easier to do it that way, other times because the rule is not clear.
Making mistakes is part of our human condition. Some errors cannot be avoided, but they can be anticipated and resolved immediately. “We cannot change the human condition, but we can change the conditions in which we work to make mistakes less likely and easier to recover from if they do occur.” (James Reason, The Human Contribution.
Errors occur at three levels of consciousness: automatic, mixed and conscious. The professional acts in routine situations, situations trained to solve problems or new situations.
In the table below, see the types of error based on skill, rules and knowledge.
Conclusion
Everyone makes mistakes. It's a characteristic that is part of our humanity.
Accepting this condition and preparing to avoid mistakes or correct them without causing harm is what safety champions do. This applies both individually and collectively.
So remember that there are recommendations and methodologies to reduce adverse events.
Understanding the psychological aspect of error, or violation, leads us to change from a punitive approach to a more investigative one..
