These professional habits can be quite effective, though they may need to be analyzed if they create conditions for error. The science of human factors attempts to circumvent habits and cognition that can create risky situations. One approach is a mindset of anticipation. The conscious adaptation of anticipating harm or mistakes is fundamentally different than the organizational pattern of simply reacting to error (Oster & Braaten, 2021). Another key concept derived from human factors is the active development of a new organizational mindset—identifying system failures versus merely identifying human failures. Of course, people are responsible for their actions within a healthcare setting; however, the system, or lack thereof, is also a considerable determining factor in adverse patient events. Gravitating to a systems perspective is essential because healthcare in general, and nursing in particular, are operations that are perpetually exposed to frequent interruptions of all kinds. This can create risk for patients, and a systems approach would seek to ameliorate this facet of the system. For example, according to Oster and Braaten (2021), nurses are interrupted approximately 12 times each working hour, and many of these interruptions occur at critical moments that can affect patient Slips, Lapses, and Mistakes James Reason, a psychologist and leading human factors researcher, has studied how people perform in complex environments and has identified three common errors in the workplace (Reason, 1990): Slips, lapses, and mistakes. Slips are errors that tend to occur during automatic, skill-based activities (Reason, 2005). Some examples are inadvertently squeezing ointment instead of toothpaste onto a toothbrush because the two tubes look alike, taking the wrong exit off the highway, or going to answer the door when the telephone rings. Distraction—whether an external stimulus in the environment (such as noise or interruption) or an internal stimulus (such as nagging worry, focused concentration on an upcoming task or event, or a physiological state such as fatigue)—creates the perfect environmental conditions for a slip (Reason, 2005). A lapse is related to cognition rather than an activity and is therefore not visible (Reason, 2005). Memory failure is an example of a lapse. Lapses tend to occur during rule-based activities such as following a diagnostic guideline or a treatment protocol, and most lapses are not conscious; a step is simply forgotten. But sometimes, under certain conditions, a worker will commit a lapse knowingly. This is most likely to happen when a guideline or protocol seems too difficult, its rationale is not understood, or time constraints make it tempting to skip a step to get the job done (Reason, 2005). A mistake is more complex than a slip or a lapse. It is a deficit or failure in judgment that occurs when specialized knowledge is required, such as when selecting a treatment goal or formulating a treatment plan (Reason, 2005). Mistakes are most likely to occur when a process is complex or when a situation is new or unfamiliar. Some mistakes, such as diagnostic judgments, may go unnoticed for a long time, and when detected, they sometimes remain a matter of debate. For example, the selection of a particular treatment plan or the decision to discharge a client from an inpatient setting is open to a range of opinions. Addressing Slips, Lapses, and Mistakes: Forcing and Constraining Concepts Human factors experts have devised strategies to compensate for slips, lapses, and mistakes. According to Reason (1990), among the basic strategies used in healthcare are redundancy functions, forcing functions, and constraining functions. Of these strategies, redundancy functions are the easiest to apply to behavioral health. A redundancy function is a checking function that builds backups or double-checks into a work process. A supervisor’s countersignature after reviewing and approving the
safety, such as during the medication administration. Oster and Braaten outline several concrete examples of how human factor thinking can be implemented. Physical Human Factors ● Modify the environment to reduce perception time, decision time, and manipulation time ● Design the environment to reduce or mitigate the need for excessive physical exertion ● Design workstations for ideal or desired physical movement Cognitive Human Factors ● Match technology with the user’s expectations and mental models ● Minimize cognitive load on staff ● Allow for error detection, recovery, and processing ● Provide timely and in-depth feedback to staff Organizational Human Factors ● Provide opportunities for staff to learn and develop new skills ● Allow staff input and control over work systems ● Support staff with access to social support ● Involve staff in system design, innovation, and evaluation 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 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).
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