Introduction
Error is inevitable, but harm is not
Sarah Corcoran, Associate Director of Clinical Effectiveness, Central Manchester Foundation Trust, 2009
This manual provides information and resources for the safe management of tracheostomy and laryngectomy care, but also is focused on the assessment and management of the acutely ill patient. Responders are frequently required to utilise their knowledge and skills to care for a collapsed, or deteriorating, patient who is only one of several concurrent responsibilities.
Although the ideal of each patient being managed by a dedicated, focused, mentally and physically fit, smoothly functioning team, without interruptions or distractions, cannot be achieved, ways of working can be adopted that optimise the quality of patient care and minimise the risk of error even under the most difficult of circumstances.
The performance of individuals and teams working in complex, high-pressure environments is influenced by a wide range of intrinsic (personal) and extrinsic (environmental) factors. Some 20 years ago, the aviation industry began to take account of these factors, how they impact on human performance and their significance for flight safety. Today, all airline staff are required to undergo a rigorous human factors training programme that equips them with the skills to recognise risky situations and behaviours and the tools to lead their team towards the safest methods of operation. More recently, this has started to be adopted within healthcare as a means of improving safety and quality. The Department of Health recommends human factors training as a way of improving safety (CMO Report 2008, Safer Medical Practice).
This chapter provides a brief overview of the human factors that can affect the performance of individuals and teams in the healthcare environment. The reader is encouraged to consider these factors in their everyday practice. Those attending the courses associated with this manual may receive direct feedback on their performance in this area. By the end of this chapter, the reader should understand the concept of human error in individuals and in teams and appreciate how situation awareness and good communication can help minimise the effects of error.
Human error
Humans make mistakes. No amount of checks and procedures will obviate this fact. Consequently, it is vital to work in a way that, as well as decreasing the occurrence of mistakes, ensures that when they do occur the resulting threat to patient safety is minimised.
Error chains
Patient safety is only rarely compromised by a single mistake. Almost always a mistake or error A leads to harm B because of a series of factors that set up the conditions such that error A resulted in event B and without which event B would not have occurred. This is known as the error chain. This is the basis of the ‘Swiss cheese’ model (Figure 13.1).
Each of the slices of cheese represents barriers that should prevent A leading to B. However, such checks and balances can fail. This is represented by the holes in the slices. For A to lead to B, the holes of all the intervening slices need to line up. Simplistically viewed, the more checks that are put in place, the less likely an error is to occur. However, increasing complexity can be counterproductive, as humans will avoid or modify multiple steps to make life easier.
We know that the clinician should have checked the details of the prescription and the calculations and ensured that this all matched up with the formulation and strength of the medications administered. People do not usually deliberately give the wrong dose and therefore it is not unreasonable to conclude that the clinician thought he had checked and matched everything as described.
Further investigation revealed that the two drugs had been replaced in one another’s normal positions in the ward trolley. The packaging of the two drugs was very similar (Figure 13.2).
Figure 13.2 Similar package designs of two different medications.
Reproduced with permission from ALSG and Dr Peter-Marc Fortune.
The clinician picked the medication from its usual place, the box having been recognised, and therefore didn’t actively check the name and concentration of the drug. Habit can blind us to what we are doing. The problems of uniform packaging have been recognised and highlighted through a national adverse incident reporting system and recommendations made that packages for different strength medications should now look completely different. This change in practice is an example of how human factors theory is used to reduce the risk of error.
In the working environment, we may be present at the right time to observe the breaching of a barrier that would normally prevent errors occurring. It is critical that we are vigilant for these breaches and draw the attention of our colleagues to them in order to prevent the completion of an error chain. Events or conditions that are suspected of representing potential breaches in barriers preventing harm are referred to as red flags. The more red flags that arise, the greater the risk of an adverse incident occurring and therefore the greater the need to alert those involved to stop and review the situation.
Communication
Problems with communication underpin a significant proportion of critical events.
When the speaker and listener do not share the same language, the obvious solution is to use an interpreter. However, there are limitations to discussions carried out through a third party. What about the issues that arise if one of the parties is communicating using their second language? Even when all parties are utilising their native tongue, non-verbal signals carry as much, if not more, information and meaning, than the words themselves. Non-verbal communication, outside the actual words we use, has been shown to contribute up to 93% of what we understand (Koneya and Barbour, 1976). Barbour’s study identified that 38% of communication relates to how words are said (volume, pitch, rhythm, etc.) and 55% body language (facial expressions, posture, etc.). When those trying to communicate come from different cultural backgrounds, both verbal and non-verbal elements can be completely misinterpreted by both parties.
Studies have shown that we understand around 60% of verbal and 50% of written communication, the remainder being miscommunicated, misinterpreted or simply misunderstood. It is not hard to see why in a busy clinical environment, when multiple tasks are being undertaken and contact is frequently electronic or telephonic, rather than face to face, miscommunication occurs so frequently. The process of communication can be described as three separate phases:
The resulting outcome in a noisy highly pressured clinical arena is unsurprisingly one of poor information exchange. A technique to improve communication is the feedback loop. This is a process by which the receiver repeats the message back to the sender to acknowledge receipt and confirm that it has been correctly deciphered. It is quick and simple to use, easy to teach and has been shown to produce immediate benefit in busy clinical areas where requests and instructions are being passed on at breakneck speed.
To aid with communication when handing over care from one team/person to another, the SBAR tool is recommended (Box 13.1).
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