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Correction of these systems failures is the key to safe performance of individuals. Systems design—how an organization works, its processes and procedures—is an institutional responsibility. Only the institution can redesign its systems for safety; the great majority of effort in improving safety should focus on safe systems, and the health care organization itself should be held responsible for safety. The committee recognizes, however, that some individuals may be incompetent, impaired, uncaring, or may even have criminal intent.

The public needs dependable assurance that such individuals will be dealt with effectively and prevented from harming patients. Although these represent a small proportion of health care workers, they are unlikely to be amenable to the kinds of approaches described in detail in this chapter. Registration boards and licensure discipline is appropriately reserved for those rare individuals identified by organizations as a threat to patient safety, whom organizations are already required by state law to report.

Historically, the health system has not had effective ways of dealing with dangerous, reckless, or incompetent individuals and ensuring they do not harm patients. Although the health professions have a long history of work in this area, current systems do not, as a whole, work reliably or promptly.

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The lack of timeliness has been a special problem. Numerous reasons have been advanced for the lack of more timely and effective response by professions and institutions. Requirements posed by legal due process can be very slow and uncertain; the need for, but difficulty in arranging, excellent supervision has stymied efforts at retraining; and matching individual needs to adult learning principles and retraining that is tailored to specific deficits has been problematic. With this acknowledged, the committee believes that health care organizations should use and rely on proficiency-based credentialing and privileging to identify, retrain, remove, or redirect physicians, nurses, pharmacists, or others who cannot competently perform their responsibilities.

With effective safety systems in place, the committee believes it will be easier for those within organizations to identify and act on information about such individuals. If these systems are working properly, unsafe professionals will be identified and dealt with before they cause serious patient injury.

Engineering the Perfect Baby

Human beings have many intellectual strengths, such as their large memory capacity; a large repertory of responses; flexibility in applying these responses to information inputs; and an ability to react creatively and effectively to the unexpected. However, human beings also have well-known limitations, including difficulty in attending carefully to several things at once, difficulty in recalling detailed information quickly, and generally poor computational ability.

Several strategies are particularly important when considering such human factors: designing jobs for safety; avoiding reliance on memory and vigilance; using constraints and forcing functions; and simplifying and standardizing key processes. Designing jobs with attention to human factors means attending to the effect of work hours, workloads, staffing ratios, sources of distraction, and an inversion in assigned shifts which affects worker's circadian rhythms and their relationship to fatigue, alertness, and sleep deprivation.

Designing jobs to minimize distraction may, for example, mean setting aside times, places, or personnel for specific tasks such as calculating doses or mixing intravenous solutions. Designing jobs for safety also means addressing staff training needs and anticipating harm that may accompany downsizing, staff turnover, and the use of part-time workers and "floats" who may be unfamiliar with equipment and processes in a given patient care unit.

2. Excessive self-blame

To the extent that these barriers presented by departmental affiliation and disciplinary training prevent caregivers from working cooperatively and developing new safety systems, job design requires attention not only to the work of the individual but also to the work and training of multidisciplinary teams.

Health care organizations should use protocols and checklists wisely and whenever appropriate. Examples of the sensible design and use of protocols and checklists are to ensure their routine updating and constructing checklists so that the usual state is answered as yes. Protocols for the use of heparin and insulin, for example, have been developed by many hospitals. Examples of attributes concerning the substance of guidelines are their validity and clinical applicability. Examples of the process of development include its clarity and documentation of the strength of the evidence.

For medications, ways to reduce reliance on memory are the use of drug-drug interaction checking software and dosing cards e.

Caution about using protocols wisely derives from the need to generalize and simplify, but to recognize that not all steps of a protocol may be appropriate. Rapid increases in knowledge and changing technology mean that a system for regular updating of protocols should be built into their production. Constraints and forcing functions are employed to guide the user to the next appropriate action or decision and to structure critical tasks so that errors cannot be made. They are important in designing defaults for devices and for processes such as diagnostic and therapeutic ordering.

When a device fails, it should always default to the safest mode; for example, an infusion pump should default to shutoff, rather than free flow. Examples of the use of constraints in ordering medications are pharmacy computers that will not fill an order unless allergy information, patient weight, and patient height are entered.

Another forcing function is the use of special luer locks for syringes and indwelling lines that have to be matched before fluid can be infused. Removal of concentrated potassium chloride from patient floor stock is a negative forcing function. Human factors research has taught us that individuals cannot remain vigilant for long periods during which little happens that requires their action, and it is unreasonable to expect them to do so.

Health care has many examples of automation used to reduce reliance on vigilance: using robotic dispensing systems in the pharmacy and infusion pumps that regulate the flow of intravenous fluids.

Although automation is intended to reduce the need for vigilance, there are also pitfalls in relying on automation if a user learns to ignore alarms that are often wrong or becomes inattentive or inexpert in a given process, or if the effects of errors remain invisible until it is too late to correct them.

Well-designed pumps give information about the reason for an alarm, have moderate sensitivity, and prevent free flow when the unit is turned off or fails. Other approaches for accommodating the need for vigilance have been developed. These include providing checklists and requiring their use at regular intervals, limiting long shifts, and rotating staff who must perform repetitive functions.

Simplifying key processes can minimize problem solving and greatly reduce the likelihood of error. Simplifying includes reducing the number of handoffs required for a process to be completed e. Examples of processes that can usually be simplified are: writing an order, then transcribing and entering it in a computer, or having several people record and enter the same data in different databases.

Other examples of simplification include limiting the choice of drugs available in the pharmacy, limiting the number of dose strengths, maintaining an inventory of frequently prepared drugs, reducing the number of times per day a drug is administered, keeping a single medication administration record, automating dispensing, and purchasing easy-to-use and maintain equipment. Standardization reduces reliance on memory. It also allows newcomers who are unfamiliar with a given process or device to use it safely.

In general, standardizing device displays e. Examples of standardizing include not stocking look-alike products; the use of standard order forms, administration times, prescribing conventions; protocols for complex medication administration; reducing the numbers of available dose strengths and the times of drug administration, placement of supplies and medications; and types of equipment. Sometimes devices or medications cannot be standardized. When variation is unavoidable, the principle followed should be to differentiate clearly.

An example is to identify look-alike, but different, strengths of a narcotic by labeling the higher concentration with bright orange tape. People work together in small groups throughout health care, whether in a multispeciality group practice, in interdisciplinary teams assembled for the care of a specific clinical condition e. However, members of the team are typically trained in separate disciplines and educational programs. They may not appreciate each other's strengths or recognize weaknesses except in crises, and they may not have been trained together to use new or well-established technologies.

The committee believes that health care organizations should establish team training programs for personnel in critical care areas e. People make fewer errors when they work in teams. When processes are planned and standardized, each member knows his or her responsibilities as well as those of teammates, and members ''look out" for one another, noticing errors before they cause an accident. In an effective interdisciplinary team, members come to trust one another's judgments and attend to one another's safety concerns. The risk associated with a move to adopt such training from fields such as aviation is in borrowing these training technologies too literally.

Although the team issues associated with performance in aviation and medicine have strong parallels in medical settings, effective training must be based not on adopting the training technologies too literally but on adapting them to the practices and personnel in the new setting. The members of a team are more than the health care practitioners. A team includes the practitioners, patients, and technologies used for the care of these patients. Whenever possible, patients should be a part of the care process.


This includes attention to their preferences and values, their own knowledge of their condition, and the kinds of treatments including medications they are receiving. Patients should also have information about the technologies that are used in their care, whether for testing, as an adjunct to therapy, or to provide patient information.

Examples of ways to share such information with patients include reviewing with patients a list of their medications, doses, and times to take them; how long to take them; and precautions about interactions with alternative therapies or with alcohol, possible side effects, and any activities that should be avoided such as driving or the use of machinery. Patients should also receive a clearly written list of their medications and instructions for use that they can keep and share with other clinicians.

Factor of safety - Wikipedia

Technology is ubiquitous in acute care, long-term care, ambulatory surgical centers, and home care. The value of automating repetitive, time-consuming, and error-prone tasks has long been understood and embraced in health care. The increasing use of technologies goes well beyond bedside or operating room devices.

It includes emerging technologies that range from molecular, cellular, genetic, and pharmaceutical interventions; to patient administered technologies e. At the same time, the human-machine interface is a focus of much preventive effort. Indeed, many technologies are engineered not only for safe operation in the care process, but specifically for the purpose of preventing error. Such technologies include automated order entry systems; pharmacy software to alert about drug interactions; and decision support systems such as reminders, alerts, and expert systems.

Health care organizations should expect any new technology to introduce new sources of error and should adopt the custom of automating cautiously, alert to the possibility of unintended harm.