A supervisor’s countersignature after reviewing and approving the clinical decisions of a student or new employee is one example of a simple redundancy function. A forcing function creates a condition that makes it impossible to commit an error. Early in the patient safety movement, a common slip—overworked nurses mistaking deadly concentrated potassium chloride with its look- alike benign saline solution—was rectified by removing potassium chloride from the nursing units in hospitals. If they needed potassium chloride, nurses had to order it from the pharmacy (Reason, 1990). A constraining function interrupts an automatic action. It creates a condition in which a worker, who is assumed to be busy and distracted, needs to pause and perform an extra step before taking a deliberate action. A constraining function interrupts the work process and causes the worker to think. Using the above example, if bags of potassium chloride were placed in a location that was not readily accessible (such as a centrally located pharmacy), the need for a nurse to leave the unit to retrieve the potassium chloride would be a constraining function. An example of a forcing function in behavioral health is a standardized suicide assessment embedded in a computer algorithm, with completion required before a patient is Preventing Harm In the language of human factors, complex organizations such as those providing medical and behavioral healthcare have insufficient layers of protection and therefore allow the mistakes made by human beings to continue on their way to cause harm. According to Bates and Singh (2018), it is commonly the cumulative effect of multiple small mistakes— each unlikely to create an accident alone, but potentially deadly when combined—that can result in a catastrophe. It follows that harm to patients can be prevented only when environmental conditions, especially broken work processes, are identified and redesigned to produce a safer system of care. Healthcare leadership will need to pave the way for durable change, changing cultural attitudes within systems of care. Leadership can inspire change to move toward preventing harm (Bates & Singh, 2018). The Swiss Cheese Model The Swiss Cheese Model (Jedick, 2022) provides a visual depiction of the ways that multiple weaknesses, both individual and organizational, can align to cause an accident. The model also shows the different points at which failures occur within an organizational system. Figure 1 illustrates the model and will be used to discuss the concepts necessary for understanding the human factors approach.
cleared for discharge. Reason (1990) outlines an example of a constraining function that uses the same computer algorithm to assess the patient’s status while not making it a condition of discharge. Another example of a constraining function is a team meeting in which all professionals involved in a client’s care provide input into readiness for discharge. Understanding human error—its frequency, type, and prevention—was important early in the patient safety movement, in part because of medicine’s longstanding and widespread tradition of focusing on people as the perpetrators of unsafe acts. Early on, such discussion was useful in that it helped professionals begin to grasp the pervasiveness of human error in the workplace. This knowledge was a beginning step toward accepting the inevitability of human error and moving away from blame. However, this narrow understanding, important as it is, fails to improve patient safety on its own because it is when human error occurs in a poorly designed system that tragedy results. To achieve safer care, the focus must be broadened beyond the individual worker to include an examination of flaws in the system of work. Safer care cannot be achieved simply by preventing error; it can be achieved only by preventing harm (Reason, 1990).
Figure 1. The Swiss Cheese Model
Note . Modified from Jedick, R. (2022). Human factors in medicine: A medical error model that isn't full of holes. Emergency Medicine News, 44(11), 24. Active and Latent Failure The Swiss Cheese Model describes two types of failures: Active and latent. An active failure is defined as an operational error at the delivery level of the organization, such as a clinician’s diagnostic error. An active failure may result from action (such as a misdiagnosis), inaction (such as failure to report abuse), or faulty decision making (following an order without questioning its appropriateness). In contrast, a latent failure is defined as an environmental factor. An environmental factor can lie dormant in an organization for days, weeks, or months, until it finally lines up with other system weaknesses and contributes to a disaster. One example of a latent failure is reduced state and federal funding for mental health services. Decreased funding produces budgetary constraints within an organization. Budgetary constraints lead to inadequate resource allocation.
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Book Code: PCUS1525
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