Human Aspects in Patient Safety
Through our professional education and culture we have incorporated certain concepts:
We are the result of our dedication and effort. We are the product of our will to be and to achieve things. Good people achieve the best results and do not make mistakes. We cannot fail. We have our free will and we make the path.
These sentences are not entirely correct.
The context in which we move 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. Understanding the context will help us improve health care.
In Patient Safety, the healthcare professional improves their performance by understanding their relationship with the context.
The operation of a hospital is a complex system and also called socio-complex, 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. We have relationships that feed back positively or negatively, etc.
Humans have a tendency to seek a linear causal relationship and to think serially (one problem after another). We usually do not see the whole field, we only see the part that corresponds to us. This leads to paradoxical (unexpected) results.
In this context, with limited resources, incomplete information, pressure on production to deliver, fatigue and multiple tasks at the same time, we have to deliver a service without errors or violations. It seems like an unequal fight.
A Patient safety makes continuous comparisons with aviation, due to the improvements they have achieved. The world of medicine is much broader than the world of aviation and many comparisons do not apply. Even so, we use this sector as a comparison for the techniques they have applied.
Most studies of accidents or adverse events (EA) focuses on human error as a trigger for disasters. We rarely see professionals as heroes, but they are often the ones who save 100 problems and make one mistake.
Recent studies of pilot operating procedure violations have found that a very high number of procedure violations were necessary for aircraft safety.
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 norm 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, 2008).
Os errors occur at three levels of consciousness: Automatic, Mixed and Conscious. The professional works in situations of: routine, situation trained to solve problems, or new situations.
In the table below, James Reason shows us the three levels of performance: skill-based, rule-based, or knowledge-based.
- Skill errors (skill-based errors). These errors are made when one is acting on an automatic (non-conscious) level and are normally called lapses or slips.
- Errors in meeting the rules (rule based errors). The failure occurs due to an error in applying the rule or due to a violation of the rule.
- Knowledge errors (knowledge based errors). They face new situations and do not apply the correct solution, due to memory lapses or lack of knowledge.
Operating in conscious mode all the time would not be possible. The brain uses pathways and shortcuts to avoid consuming energy. Our attention is not unlimited. If we receive input in the middle of a task, we may lose the automaticity, even of something we know well.
When the mind searches for information in our memory, we call that packet of information, based on similarity and most frequent or recent use. We compare the information we receive with the information we have stored, following these rules: similarity and frequencyThis can easily lead us into error, because the mind, out of economy, does not analyze all possibilities. If it is working based on knowledge, and memory sends wrong data, the activity will be wrong.
The only way to reduce our risk is to create a series of barriers, with several layers, that prevent the error, or even, when it happens, that mitigate its consequences.
Barriers can be personal habits or systemic procedures.
It is necessary to understand the differences between causes and conditions of error. The conditions are present in cases with poor results and in others, where nothing serious happened. The condition for the failure, also called a pathogenic condition or latent failure, does not generate problems until the cause appears. The cause is the trigger for an existing failure, dormant within the organization or process.
The model presented below is an evolution of the Swiss cheese model by James Reason himself. This author devoted more than 40 years to the study of accidents and errors.
The failure conditions are separated by type: Organizational Culture and Work Environment. Although both are part of the context, the first has a more generic and cultural characteristic and the second, more physical and related to the moment of the incident.
Conclusion
Everyone makes mistakes. It is a characteristic that is part of our humanity.
Accepting this and preparing to avoid mistakes, or correct them without harm, is what safety champions do.. The same goes on an individual as well as a collective level.
- The best organizations embrace a culture of transparency and mutual trust.
- Mistakes allow us to learn and improve. You can learn a lot from near misses (near miss) with a low damage cost.
- Strongly hierarchical systems (power) do not help to develop security. Responsibility must be passed to those who can best resolve security issues (expertise).
- People and organizations operate on the principle of least effort. Violations of the rules will be common if the procedure is not easy to perform.
- The solution to a complex problem must have an equal level of complexity to solve it. A simple answer to a complex problem is a methodological error, regardless of the answer.
- Every person and every organization has their own “latent errors or resident pathogens” that are waiting for a trigger to become reality.
- We must avoid superficial answers based on experience or criteria, based on common sense. We need to delve deeper into the questions and answers of each problem.
- How the mind works by searching memory to find a pattern, based on what is similar and frequent, and not on all the information we have, we are always prone to making mistakes. Developing habits to avoid these mistakes is our goal as professionals.
In other words, 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.
Victor Basso
director of Opuspac Ltda.
Opuspac University (corporate university – educational arm of Opuspac Ltd)
