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					                                     H E A LT H CA R E    Q UA L I T Y




                       Reduce Human Error
           How to analyze near misses and sentinel events,
        determine root causes and implement corrective actions
                                                    by
             James J. Rooney, Lee N. Vanden Heuvel and Donald K. Lorenzo




W
                  HAT CAUSED THE last sen-                 Historically, human errors are significant fac-
                  tinel event (an unexpected             tors in almost every quality problem, equip-
                  occurrence involving death or          ment shutdown or accident in industrial and
                  serious physical or psycholog-         manufacturing facilities. One study of refining
                  ical injury) at your healthcare        and petrochemical plants identified the follow-
                  facility? The last quality of          ing causes of accidents: equipment and design
care problem? The last near miss? In most                failures, 41%; operator and maintenance errors,
cases, human error is determined to be either            41%; inadequate or improper procedures, 11%;
the direct cause—a pharmacist incorrectly fill-          inadequate or improper inspection, 5%; and
ing a medication order, or a nurse failing to            miscellaneous causes, 2%.1
respond to an IV alarm—or a significant con-               An adverse event in the healthcare field is
tributor—an oxygen bottle running empty                  defined as an injury caused by medical man-
when the technician fails to notice it needs             agement rather than by the patient’s underlying
replacing.                                               disease or condition. 2 Not all, but a sizable
   In many cases, if the human mistake results           number, of adverse events are the result of
in only a minor quality of care problem, no fol-         human error.
low-up action is necessary. However, if this               A Harvard Medical Practice study examined
human mistake results in a near miss or sen-             more than 30,000 randomly selected discharges
tinel event, a report will be completed, and the         from 51 randomly selected hospitals in New
responsible person might be coached, disci-              York in 1984 (the most recent statistics avail-
plined or maybe even fired. As a result, most            able).3 Adverse events occurred in 3.7% of the
managers and team leaders feel relatively confi-         hospitalizations. The proportion of adverse
dent the mistake will not occur again. However,          events attributable to errors was 58%, while the
experience shows us mistakes will likely recur.          proportion due to negligence was 27.6%.

                                                     QU A L I T Y P R O G R E S S   I   S E P T E M B E R   2 0 0 2   I   27
REDUCE HUMAN ERROR




 FIGURE 1           Random                         FIGURE 2           Systematic                 FIGURE 3           Sporadic
                    Variability                                       Variability                                   Variability




  5   6   7   8 9     10                            5   6   7   8 9    10                         5   6   7   8 9     10




Although most of these adverse events resulted in                           wrong type of medication or administer the medica-
disability lasting less than six months, 13.6% resulted                     tion to the wrong patient.
in death and 2.6% caused permanently disabling                                 All these variations are inconsequential unless they
injuries. The most common adverse events were:                              cause an adverse impact on the quality of care, such as
• Drug complications, 19%.                                                  extended hospitalization, temporary or permanent
• Wound infections, 14%.                                                    injury to the patient or even death. In such cases, the
• Technical complications, 13%.                                             variation would be considered a human error.
   Today, the challenge for healthcare management is                        Unfortunately, these limits of variability are usually not
to implement systems to reduce the frequency of                             well-defined until a person makes a mistake that results
human errors and devise ways to mitigate the conse-                         in a problem big enough to warrant corrective action.
quences of the errors that do occur. Instead of blaming
                                                                            Human errors
human error on ill trained or unmotivated workers,
systems must be established to investigate and ana-                           Human errors are divided into two types:
lyze near misses and sentinel events so root causes can                     • Unintentional errors: Actions committed or omit-
be determined and corrective actions implemented.                             ted with no prior thought. These errors, such as
By doing this, healthcare teams should begin to expe-                         misreading a gage, bumping the wrong switch or
rience significant improvements in overall system per-                        forgetting to properly set the dose on an X-ray
formance and safety.                                                          device, are usually thought of as accidents.
                                                                            • Intentional errors: Actions deliberately committed
Understanding human error                                                     or omitted because workers believe their actions are
   Opportunities for error exist in every task per-                           correct or better than the prescribed actions. For
formed by a nurse, physician or any other healthcare                          example, a physician might intentionally perform
employee. Even though a single task may never be                              an erroneous action if the cause of a patient’s symp-
performed exactly the same way twice, minor varia-                            toms is misdiagnosed. Other intentional deviations
tions in performing a task are usually of no concern.                         include shortcuts that are not recognized as human
However, when some limit of acceptability is exceed-                          errors until circumstances arise in which the actions
ed, a variation is considered a human error.                                  exceed the system tolerances. To speed up the filling
   Human error is any human action or lack thereof                            of an automated medication dispenser unit, for
that exceeds the tolerances defined by the system with                        example, a pharmacy technician might not perform
which the human interacts. 4 For example, a nurse                             the verifications specified by the procedure.
asked to administer a medication to a patient might                           Remember, the important distinction between an
administer too much or too little, administer the                           intentional deviation and malevolent behavior is


28    I   S E P T E M B E R   2 0 0 2   I   W W W . A S Q . O R G
motive. An intentional deviation is not intended to
harm the system, but its effect on the system may be                               TABLE 1           Internal Performance
undesirable. A malevolent act is not an error—it is a                                                Shaping Factors
deliberate action intended to produce a harmful effect.
                                                                                    Training/skill                        Emotional state
The term “human error” in this article does not
                                                                                    Practice/experience                   Gender
include malevolent acts.
                                                                                    Knowledge of required                 Physical condition/health
                                                                                       performance standards
Variability                                                                                                               Influences of family and other
                                                                                    Stress: mental or bodily tension         outside persons or agencies
   Even though a nurse, doctor or instrument special-                               Intelligence                          Group identifications
ist may be well-trained and highly motivated, human                                 Motivation/work attitude              Culture
errors are still a natural and inevitable result of the                             Personality
variability of human interaction with a system. There
are three types of variability. Knowing which one             Source: A.D. Swain and H.E. Guttmann, Handbook of Human Reliability Analysis With Emphasis on
                                                              Nuclear Power Plant Applications (Washington, DC: U.S. Nuclear Regulatory Commission, 1985).
occurs in a given case will help explain why errors
happen and what can be done to control
them. To understand these types of vari-
ability, think of a rifleman firing 10 shots
at a target, and consider any shot off the
target an error:
                                                                    ASQ Lends a Hand
• Random variability: Characterized
   by a dispersion pattern centered
                                                               At Reducing Healthcare Errors
   around a desired norm—in this                  Although widespread agreement exists on the causes of prescrip-
   example it’s the bull’s-eye (see Figure    tion drug errors, there is little consensus on the methods needed to
   1). Personnel selection, training,         address these problems. A new paper presented to congressional
   supervision and quality control pro-       health policy staff by ASQ advocates the wider adoption of proven
   grams are all ways to control random       quality methods in an effort to reduce medication errors.
   variability. Random errors occur               As part of the Society’s ongoing effort to cultivate contacts with
   when these programs are deficient,         national policymakers in Washington, DC, ASQ officials met with the
   when tolerance limits are too tight or     health policy advisor to Congressman Michael Bilirakis of Florida ear-
   when workers cannot control key            lier this year. The advisor asked for suggestions from ASQ on ways
   performance factors.                       quality methods could be used to reduce prescription drug errors.
• Systematic variability: Characterized           ASQ staff, with input from members of the Health Care Division
   by a dispersion pattern offset from a      and the Food, Drug & Cosmetic Division, prepared a position paper
   desired norm (see Figure 2). Such          titled “Using Quality Methods To Reduce Prescription Drug Errors.”
   errors are called systematic errors.       It is available at www.asq.org/news/
   These errors occur, for example, when      interest/prescription.pdf.
   workers are given only one limit               ASQ has also joined with the National
   instead of a lower and upper limit. In     Patient Safety Foundation (NPSF) to form
   this case, they may deliberately try to    an alliance that will offer solutions for
   be on the safe or unlimited side.          reducing errors and increasing patient
   Biases can also exist in tools, equip-     safety in healthcare delivery. The two
   ment, instructions or the worker ’s        groups will collaborate to develop a tool-
   personality, training or experience.       box of products and services for leaders
   Telling workers how well they are          of healthcare organizations and acute care settings to increase patient
   doing with respect to real goals will      safety. ASQ-NPSF events will share successful case study implemen-
   help reduce systematic errors.             tation of the toolbox methods such as Six Sigma and distribute
• Sporadic variability: Characterized         applicable patient safety solutions to various healthcare channels.
   by an occasional outlier, such as a            For more information on the NPSF, go to www.npsf.org.
   tight cluster of shots with one shot
   substantially off the mark for reasons

                                                                              QU A L I T Y P R O G R E S S      I      S E P T E M B E R   2 0 0 2   I     29
REDUCE HUMAN ERROR




     that are readily imaginable, such as a sudden dis-                                                are not the result of inadequate knowledge or moti-
     traction or an involuntary twitch (see Figure 3,                                                  vation. To reduce sporadic errors, we must catego-
     p. 28). These errors are often not correctable by                                                 rize the errors and the conditions under which they
     additional training or indoctrination because they                                                occur in such a way that the errors can be related to
                                                                                                                    controllable conditions.

                                                                                                                     Performance shaping factors
 TABLE 2                External Performance Shaping Factors
                                                                                                                        Healthcare workers are an essential ele-
                                                             Task, equipment and
                                                                                                                     ment of any healthcare system. To mini-
     Situational characteristics                             procedural characteristics                              mize human errors in medical activities,
                                                                                                                     managers must ensure the healthcare
     Architectural features                                  Procedures: written or not written
     Environment: temperature, humidity,                     Written or oral communications
                                                                                                                     worker/machine interface, including
      air quality, lighting, noise, vibration                Cautions and warnings                                   interactions with other workers and with
      or general cleanliness                                                                                         the equipment and environment, is com-
                                                             Work methods/practices
     Work hours/work breaks                                  Dynamic vs. step-by-step activities                     patible with the capabilities, limitations
     Shift rotation                                          Team structure and communication                        and needs of the worker.
     Availability/adequacy of special                        Perceptual requirements
      equipment, tools or supplies                                                                                      A performance shaping factor (PSF) is
                                                             Physical requirements: speed                            anything that affects a worker’s perfor-
     Staffing levels                                           and strength
     Organizational structure: authority,                    Anticipatory requirements
                                                                                                                     mance of a task within the system. PSFs
      responsibility or communication                                                                                can be divided into three classes:5
      channels                                               Interpretation/decision making
                                                             Complexity: information load                            • Internal PSFs that act within an individ-
     Actions by supervisors,
      co-workers or accreditation and                        Long- and short-term memory load                           ual.
      regulatory personnel                                   Calculational requirements                              • External PSFs that act on an individual.
     Facility policies                                       Feedback: knowledge of results                          • Stressors.
                                                             Hardware interface factors: design of
                                                                                                                        Internal PSFs are the individual skills,
                                                               control equipment, test equipment,
                                                               process equipment, job aids or tools                  abilities, attitudes and other characteris-
                                                             Control-display relationships                           tics a worker brings to the job (see Table
                                                             Task criticality                                        1, p. 29). Some of these, such as training,
                                                             Frequency/repetitiveness                                can be improved by managers; others,
 Source: A.D. Swain and H.E. Guttmann, Handbook of Human Reliability Analysis With Emphasis on Nuclear Power Plant   such as a short-term emotional upset trig-
 Applications (Washington, DC: U.S. Nuclear Regulatory Commission, 1985).
                                                                                                                     gered by a family crisis, are beyond any
                                                                                                                     practical management control.
                                                                                                                        Table 2 lists external PSFs that influ-
 TABLE 3                Psychological and Physiological Stressors
                                                                                                                     ence the environment in which tasks are
                                                                                                                     performed. External PSFs are divided
     Psychological stressors                                Physiological stressors
                                                                                                                     into two groups:
     Suddenness of onset                                    Long duration of stress                                  • Situational characteristics: General
     High task speed                                        Fatigue
                                                                                                                        PSFs that may affect many different
     Heavy task load                                        Pain or discomfort
                                                                                                                        jobs.
     High jeopardy risk                                     Hunger or thirst
     Threats of failure or loss of job                      Temperature extremes
                                                                                                                     • Task, equipment and procedural char-
     Monotonous, degrading or meaningless                   Radiation                                                   acteristics: Related to a specific job or a
       work                                                 Exposure to diseases                                        specific task within a job. Job and task
     Long, uneventful vigilance periods                     Vibration                                                   instructions are a particularly impor-
     Conflicting motives about job performance              Movement constriction                                       tant part of the task characteristics
     Negative reinforcement                                 Movement repetition                                         because they have such a large effect
     Sensory deprivation                                    Lack of physical exercise
                                                                                                                        on human performance. By emphasiz-
     Distractions: noise, glare or movement                 Disruption of circadian rhythm
     Inconsistent cueing                                                                                                ing the importance of preparing and
     Lack of rewards, recognition or benefits                                                                           maintaining clear, accurate task
 Source: A.D. Swain and H.E. Guttmann, Handbook of Human Reliability Analysis With Emphasis on Nuclear Power Plant
                                                                                                                        instructions, managers can significantly
 Applications (Washington, DC: U.S. Nuclear Regulatory Commission, 1985).                                               reduce the likelihood of human errors.

30      I    S E P T E M B E R       2 0 0 2       I     W W W . A S Q . O R G
   Mismatches between internal and
external PSFs result in disruptive stress
that degrades job performance.
   If too little stimulation is present, a
                                                  ASQ Facilitates Application
worker will not remain sufficiently alert
or motivated to do a good job. For
example, a pharmacy worker who
                                                  Of ISO 9000 to Healthcare
repetitively fills medication orders may        By Michael Stoecklein, ASQ’s healthcare market devel-
                                                opment manager, and Mickey Christensen, Health Care
not be alert enough to notice a tablet
                                                                Division standards committee chair
was omitted.
   On the other hand, too much stimula-
tion will quickly overburden a worker            Since the publication of the Institute of Medicine’s 1999 report To
and degrade job performance. In such           Error Is Human: Building a Safer Health System, there has been
situations, workers tend to focus on the       increasing interest in trying to identify and use methods to help reduce
largest or most noticeable signals and         errors and improve safety while simultaneously improving an organi-
ignore some information entirely, omit         zation’s operating margin. Other industries have proven ISO 9000 is a
or delay some responses, process infor-        very powerful quality management tool, and some healthcare service
mation incorrectly and reject informa-         organizations have found it can help provide better healthcare systems
tion that conflicts with their diagnosis or    and reduce the incidence of avoidable adverse events.
decision, or mentally or physically with-        ASQ’s Health Care Division and the Automotive Industry Action
draw. See Table 3 for some examples of         Group collaborated to develop ISO 9004:2000 based document guide-
disruptive psychological and physiolog-        lines for process improvements in health service organizations.
ical stressors.                                ASQ’s Health Care Division helped lead the group effort in drafting
   Although stress usually has a nega-         the document. At an international workshop in 2001, attendees modi-
tive connotation, some stress is actually      fied the draft, which was later accepted for publication by the
necessary for humans to function at            International Organization for Standardization, known as ISO. After
optimum performance (see Figure 4,             the workshop in Detroit, the attendees voted to publish the ISO IWA-1
p. 32). Facilitative stress is anything that   document.
arouses us, alerts us, prods us to action,       The IWA-1 document can be used by healthcare organizations to
thrills us or makes us eager. When a           implement an ISO 9000 quality based management system and make
positive balance exists between internal       accreditation with other agencies easier, thereby minimizing the num-
and external PSFs, workers experience          ber of resources required to comply. IWA-1 contains much of the text
facilitative stress and their job perfor-      of ISO 9004:2000 but also includes specific guidance for its implemen-
mance is at its best.                          tation in the healthcare sector.
   Managers must recognize most PSFs,            The guidelines are voluntary and
including many internal PSFs, are with-        not intended for certification or
in their control. By designing work situ-      accreditation. Copies of the IWA-1 doc-
ations that are compatible with human          ument and the reports published by
needs, capabilities and limitations, care-     the Institute of Medicine are available
fully matching workers with job                from ASQ Quality Press, http://quality-
requirements, and rewarding positive           press.asq.org.
behaviors, managers can create condi-            ASQ has also developed a training course, IWA-1 Train the Trainer,
tions that optimize worker performance         and some training materials. The next course is scheduled for Sept.
and minimize human errors.                     23-26 in San Diego. Go to www.asq.org/ed/courses/descriptions/
                                               iwahealthcare.html for more information.
General approaches for reducing human error      In addition, ASQ recently began hosting quality conversations on a
  When contemplating ways to                   variety of topics, the most recent being one about Six Sigma in
improve human performance, managers            healthcare. To read a copy of the transcript, go to www.asq.org/
must address two basic types of errors:        ed/qconvs/062002sixsigmahc/index.html.
• Those whose primary causal factors

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REDUCE HUMAN ERROR




   are individual human characteristics
   unrelated to the work situation.             TABLE 4           When To Use a Self-Checking Technique
• Those whose primary causal factors
                                                   1. Are you unsure about the intent           6. Is this a routine or boring,
   are related to the design of the work
                                                      of the steps or the task or                  but critical task?
   situation.                                         performance standards?
   Employing appropriate hiring and job            2. Are you confused or do you sense          7. Can you clearly see and identify
assignment policies is an important                   something is not right?                      the equipment you are working on?
means for managers to reduce the causes
of the first type of error. But, on any given      3. Has the task been interrupted,            8. Do you have insufficient indication
day, a worker could be emotionally upset              causing you to begin the task                of system or component status?
                                                      again, or is it a departure from a
or fatigued and commit an error even                  well-established routine?
though human factors specialists estimate
                                                   4. Have you received verbal instruc-         9. Have you had an unexpected
only 15 to 20% of workplace errors are                tions on performing the task?                encounter with a system, system
primarily caused by such internal human                                                            interlock or system alarm?
conditions.  6
                                                   5. Are you hurried or performing            10. Are you fatigued?
   The majority, 80 to 85%, of human                  several tasks simultaneously?
errors result from the design of the work
situation, such as the tasks, equipment
and environment.7 Managers can directly                              Here are two examples that can serve as a starting
control these factors. A work situation where the PSFs           point in identifying error likely situations in your own
are not compatible with the capabilities, limitations or         healthcare facility:
needs of an employee is called an error likely situa-            1. A 6-year-old boy died after undergoing a magnetic
tion. In a sense, an error likely situation is one in                resonance imaging (MRI) exam when the
which a person has unintentionally been set up to                    machine’s powerful magnetic field jerked a metal
make a mistake. Error likely situations can result from              oxygen tank across the room and crushed the
a variety of causes:                                                 child’s head. The force of the device’s 10-ton mag-
• Deficient procedures.                                              net is about 30,000 times as powerful as the Earth’s
• Poor communication between workers.                                magnetic field, and 200 times stronger than a com-
• Inadequately trained workers.                                      mon refrigerator magnet.
• Conflicting interests of workers.                              2. A bar coding system was implemented for the
• Inadequately labeled equipment.                                    administration of medications. When the system
• Poorly designed equipment.                                         was designed, the display units were intended to be
                                                                                  used at the patient’s bedside. However, the
                                                                                  batteries in the units run down so quickly
  FIGURE 4      Facilitative Stress                                               the staff ends up leaving them plugged in
                                                                                  in the hallway. Now the nurses cannot see
      Very
                                   Task load                                      or hear the terminal indications when they
      low          Optimum           Heavy                                        administer medications to patients.
 High
                                                                                  By providing the resources necessary to
 Performance effectiveness




                                                                              identify and eliminate error likely situations,
                                                                              managers can improve the PSFs and dramat-
                                                           Threat             ically reduce the frequency of human errors.
                                                           stress
                                                                              This strategy is called the work situation
                                                                              approach and involves the five elements
                                                                              described below.
                                                                                  To maximize the benefits of such a strate-
 Low                                                                          gy, managers should solicit healthcare work-
      Very         Optimum        Moderately             Extremely            ers’ input into this strategy at every
      low                             high                  high
                                                                              opportunity. After all, the workers can best
                                  Stress level
                                                                              identify the factors that hinder their perfor-

32                           I   S E P T E M B E R   2 0 0 2   I   W W W . A S Q . O R G
mance and will likely support such
a strategy if they are not penalized
for telling the truth.                        Leapfrog Group Forms Coalition
Element 1: Implement good human factors
engineering
   Human factors engineering and
                                                 To Improve Patient Safety
ergonomics are concerned with                 In response to a serious problem, the Leapfrog Group, a coalition of
ways to design jobs, machines, oper-       more than 100 public and private organizations that provide healthcare
ations and work environments so            benefits, is taking action. The group was created to help save lives and
they are compatible with human             reduce preventable medical mistakes. It mobilizes employer purchas-
capacities and limitations. Many           ing power to initiate breakthrough improvements in healthcare safety
human errors in healthcare are             and gives consumers information to make more informed hospital
caused by equipment and work               choices.
environments that were not initially          This voluntary program is aimed at getting large purchasers to alert
designed with an emphasis on main-         the healthcare industry that big leaps in patient safety and customer
tainability and human factors engi-        value will be recognized and rewarded with preferential use and other
neering principles. Maintainability is     intensified market reinforcements. The Leapfrog Group was founded
the probability a piece of equipment       by the Business Roundtable, a national associa-
will be restored to specified condi-       tion of Fortune 500 CEOs.
tions within a given period after             Hospitals are already taking important steps
maintenance is performed in accor-         to ensure patients’ safety. Based on over-
dance with prescribed procedures           whelming scientific evidence, the Leapfrog
and resources.                             Group decided to focus on three practices that
   A new system design should              have tremendous potential to save lives:
account for all necessary mainte-          • Computerized physician order entry.
nance behaviors through proper             • Evidence based hospital referral.
labeling; accessibility for repair,        • ICU physician staffing.
removal and replacement; proper               While these steps will not prevent all mistakes in hospitals, they are
inspection and testing; and avail-         a vital first effort. For more information on the Leapfrog Group and
ability of spare parts and tools.          these practices, visit www.leapfroggroup.org.
Some examples include knobs that
can be grasped and turned with
reasonable force, labels that can be
read from a reasonable distance and critical or unique        potential error likely situations. Having these
tools permanently located at the job site.                    resources available during design reviews has other
   Identification and elimination of error likely situa-      advantages, too. It helps:
tions early in the system design phase are obviously          • Provide a cost effective and practical way to resolve
more desirable than the frustrating and costly task of           the identified problem areas.
retrofitting. Because most system designs are based on        • Provide an excellent opportunity for training on the
a similar system currently in service, it would be pru-          new process.
dent to evaluate the existing system to help determine        • Develop a sense of ownership of the new process
future requirements.                                             among workers.
   Reviewing old drawings, performing walk-
throughs and interviewing physicians and nurses are           Element 2: Provide clear, accurate procedures and instructions
worthwhile ways to evaluate an existing system.                  Many human errors in healthcare can be prevented
Including these personnel in design reviews or as per-        by ensuring clear, accurate procedures and job aids are
manent members of the design team are good ways to            available and used by all workers. This will help
involve the users of the new process and draw on              reduce workers’ reliance on skill and memory to per-
their knowledge and experience to help identify               form a task, assist workers in decision making and

                                                              QU A L I T Y P R O G R E S S   I   S E P T E M B E R   2 0 0 2   I   33
REDUCE HUMAN ERROR




                                                                                                        criticality of the task, but it is important to
 FIGURE 5            Conversion of Knowledge to Skill                                                   include warnings, cautions and other crit-
                                                                                                        ical parameters for workers at all levels of
                    End of initial training                                                             expertise.
 High               and practice
                                                                                                      • Use language understandable to the
                                                                          With practice of              worker to reduce the potential for errors,
                                                                          simulated upsets              especially in stressful situations. Pro-
                                                                                                        cedures can be made more understand-
                                                                                                        able if you include only one action in each
                                                                                                        procedure step and use short but com-
                                                                                                        plete language, active voice, simple sen-
                                                                                                        tences and positive phrases.
                                                                     With no further practice           Besides being well-written, procedures
                                                                                                      and job aids must be readily available to
 Low                                                                                                  workers. Ideally, the procedures should be
                                                   Time                                               located where they will be used. For exam-
                       Vertical arrows represent practice sessions such as drills,                    ple, the directions on how to use an auto-
                        talk-throughs, what-if challenges and simulator training.                     clave to clean surgical instruments should
                                                                                                      be located on the front of the machine. If
                                              Response skills
                                                                                                      that’s not possible, a single set of procedures
                                                                                                      should be kept in a centrally located place.
help ensure a given task is performed consistently.
                                                                                         Element 3: Provide job relevant training and practice
   Written procedures provide step by step directions
describing how and when to perform portions of the                                          Training ensures healthcare workers possess the
task. Job aids such as flowcharts, decision tables and                                   basic skills necessary to effectively perform their func-
checklists can be used to concisely organize informa-                                    tions. Several types of training have proven most
tion needed to perform problem diagnosis and aid                                         effective in reducing human errors, including initial
workers who are performing tasks involving numer-                                        skill training, refresher training and management sys-
ous steps.                                                                               tems training.
   You can increase a procedure or job aid’s effective-                                     Initial skill training is generally conducted in the
ness by incorporating these key principles:                                              classroom and supplemented with on-the-job experi-
• Select a procedure style or format that is usable,                                     ence. It prepares workers for experiences they will rou-
   familiar and best communicates the information to                                     tinely encounter and those they will infrequently
   the worker.                                                                           encounter. If training does not include the infrequent
• Ensure the procedure is accurate and complete to                                       events or situations, the likelihood of successfully han-
   maintain credibility and guarantee continued use. If                                  dling such situations will depend solely on the prob-
   procedures contradict the way tasks are performed                                     lem solving and decision making skills of the worker.
   in practice, workers will soon lose faith in the proce-                                  In addition to initial training, refresher training on
   dures and will not use them. Involving experienced                                    nonroutine or modified tasks will minimize worker
   workers in procedure development and establish-                                       errors and reduce the potential for a worker’s skills to
   ing a proper frequency for updating procedures will                                   deteriorate. A refresher training program is needed to
   help create and maintain accurate procedures. To                                      assist workers in developing and maintaining a high
   further ensure procedures remain accurate, experi-                                    skill level. Such a program will address a worker’s loss
   enced workers should conduct a periodic review.                                       of skills and enhance skills beyond the initial training
• Include the appropriate level of detail in each proce-                                 level.
   dure. Too little detail will make the procedure unus-                                    The sawtooth curve in Figure 5 presents the potential
   able by the inexperienced worker, and too much                                        benefits of a refresher training program on worker
   detail may discourage the experienced worker from                                     responses vs. performing only initial training. The
   using it. The appropriate level of detail will be                                     curve illustrates the conversion of knowledge to skill
   determined by the level of worker expertise and the                                   through repeated training and practice.

34      I   S E P T E M B E R     2 0 0 2      I    W W W . A S Q . O R G
  To round out a healthcare training program, man-                       vate workers to improve their levels of performance.
agement system training is required on a regular basis                     A motivated workforce with a positive attitude is
to ensure healthcare workers can readily identify and                    less likely to commit errors; therefore, a healthcare
follow relevant management systems. For example, on                      team leader or supervisor should introduce various
many safety critical systems, a management system                        motivational factors into the work situation:
exists to help prevent systematic human variability. To                  • Recognize achievement. Praise a technician in the
prevent a common cause human error, many hospitals                         presence of his peers.
have policies for redundant checking of medication                       • Provide access to information. Train a nurse’s aide
and treatments. Many of these systems are in place to                      to obtain information on a computer system nor-
prevent human errors and should not be overlooked                          mally used only by the nurses.
when developing a healthcare training program.                           • Allow use of one’s ability. Allow a physician who
                                                                           is familiar with computers to provide input into the
Element 4: Provide ways to detect and correct human errors                 selection of the hardware and software for the new
   Many human errors in healthcare can be prevented                        computerized healthcare management system.
by implementing certain administrative controls and                      • Give challenging assignments. Give the central
systems. For instance, some companies have policies                        stores staff the opportunity to help determine the
that require healthcare workers to work in pairs for                       optimum distribution of medical gas bottles to units
certain activities. This buddy system can be effective                     in the hospital.
in detecting a human error before an undesired conse-                    • Assign extended responsibilities. Allow a clerk
quence occurs.                                                             who has shown both the interest and the ability to
   For example, after an X-ray technician finishes work                    move into a healthcare position.
on a patient, the X-rays can be viewed to verify the                     • Provide the freedom to act. Empower a technician to
work was satisfactory. Healthcare workers should                           requisition a new testing instrument without prior
identify opportunities to proof their work to detect                       approval from his or her immediate supervisor.
mistakes before patients are returned to their rooms                     • Seek involvement in planning, problem solving or
and the equipment is returned to service. Whenever                         goal setting. Invite healthcare workers to partici-
possible, these proofs should be incorporated into                         pate in quality of care investigations, healthcare
written procedures to help guarantee they are per-                         budget forecasting or goal setting.
formed and to provide training for new employees.
                                                                         Improve overall system performance
   Another way healthcare workers can detect and
correct human error is by using self-checking tech-                         Many times, human errors are the result of error
niques. A self-checking technique is a practice in                       likely situations that come about due to the way the
which a person consciously and deliberately reviews                      procedures are written, the training is conducted, or
the intended action and expected response before per-                    the systems are designed, operated or maintained.
forming a task. One technique is the five “rights” used                  Today’s management is challenged by a paradigm
to administer medications:                                               shift from blaming mistakes on carelessness and
• Right patient.                                                         incompetence to implementing methods to identify
• Right medication.                                                      the root cause of why a person makes a mistake.
• Right dose.                                                               Allocating time and resources to understanding
• Right route.                                                           human factors, and identifying and eliminating error
• Right time.                                                            likely situations through methods such as the work
                                                                         situation approach, will significantly help improve
Element 5: Help workers achieve their social and psychological needs     overall system performance and process safety.
   Worker motivation will likely be high if manage-
                                                                         ACKNOWLEDGMENTS
ment applies accepted human factors principles to job
                                                                           We would like to thank Myron Casada, Vernon Guthrie,
tasks, training provides the necessary skills to handle
                                                                         Maureen Hafford, Leslie Adair and Angie Nicely for their assistance
all contingencies and workers are actively involved in
                                                                         with this article.
their jobs through participation strategies. In addition,
many first-line healthcare managers are given the                        REFERENCES
opportunity to shape the work environment and moti-                         1. R.E. Butikofer, Safety Digest of Lessons Learned

                                                                       QU A L I T Y P R O G R E S S   I   S E P T E M B E R   2 0 0 2   I   35
REDUCE HUMAN ERROR




(Washington, DC: American Petroleum Institute, 1986).                4. D.K. Lorenzo, A Manager’s Guide to Reducing Human
   2. T.A. Brennan, “Incidence of Adverse Events and               Errors: Improving Human Performance in the Chemical Industry
Negligence in Hospitalized Patients: Results of the Harvard        (Washington, DC: American Chemistry Council, 1990).
Medical Practice Study I,” New England Journal of Medicine, Vol.     5. A.D. Swain and H.E. Guttmann, Handbook of Human
324, No. 6.                                                        Reliability Analysis with Emphasis on Nuclear Power Plant
   3. L.L. Leape, “The Nature of Adverse Events in                 Applications (Washington, DC: U.S. Nuclear Regulatory
Hospitalized Patients: Results of the Harvard Medical Practice     Commission, 1985).
Study II,” New England Journal of Medicine, Vol. 324, No. 6.         6. A.D. Swain, Design Techniques for Improving Human
                                                                                       Performance in Production (Albuquerque,
                                                                                       NM: Industrial and Commercial Tech-
                                                                                       niques, 1986).
                                                                                          7. Ibid.

                                                                                      JAMES J. ROONEY is a senior risk and
                                                                                      reliability engineer with ABS Consulting’s
                                                                                      risk consulting division in Knoxville, TN.
                                                                                      He earned a master’s degree in nuclear
                                                                                      engineering from the University of
                                                                                      Tennessee. Rooney is a Fellow of ASQ and
                                                                                      an ASQ certified quality auditor, quality
                                                                                      auditor-HACCP, quality engineer, quality
                                                                                      improvement associate, quality manager
                                                                                      and reliability engineer.

                                                                                      LEE N. VANDEN HEUVEL is a senior risk
                                                                                      and reliability engineer with ABS
                                                                                      Consulting’s risk consulting division in
                                                                                      Knoxville, TN. He earned a master’s degree
                                                                                      in nuclear engineering from the University
                                                                                      of Wisconsin. Vanden Heuvel co-authored
                                                                                      the Root Cause Analysis Handbook.

                                                                                      DONALD K. LORENZO is a senior risk and
                                                                                      reliability engineer with ABS Consulting’s
                                                                                      risk consulting division in Knoxville, TN.
                                                                                      He earned a master’s degree in nuclear
                                                                                      engineering from the Georgia Institute of
                                                                                      Technology. He authored A Manager ’s
                                                                                      Guide to Reducing Human Errors:
                                                                                      Improving Human Performance in the
                                                                                      Chemical Industry and is director of the
                                                                                      Process Safety Institute. QP




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