Open | System changes and human factors to prevent harm and errors
Harm from high-risk medicines can be reduced by putting interventions in place to address the reasons for an error occurring. Interventions can include guidelines, staff education and system improvements, which reduce the risk of errors being made and prevent potential harm to the patient.
Removing the potential for error is the most effective error prevention strategy. This type of system change is called a high leverage strategy, for example, not stocking, or locking away, potassium chloride concentrated injections to prevent incorrect administration. Other high leverage strategies are automation and computerisation.
Medium leverage strategies include standardisation, independent double checking and using checklists. These strategies do not eliminate hazards but reduce the likelihood of errors occurring.
For example, independent double checking of the dose calculation can prevent overdose due to calculation error. The ‘independent’ factor is the important part – performing the calculation independently and comparing it your colleague’s calculation reduces the chance of error.
Low leverage strategies include guidelines, protocols, education and training. For example, a protocol for the management of anticoagulants including unfractionated heparin and warfarin will help prescribers and administrators manage these medicines. Both medium and low leverage strategies require constant updating and reinforcement to maintain knowledge and currency. The next edition of Medication Safety Watch discusses leverage strategies in more detail. Subscribe to Medication Safety Watch.
It is important to also recognise human factors when preventing harm and errors. Human factors encompass a range of things that can influence people and their behaviour such as environmental, organisational, job factors and individual characteristics. Some common human factors that can increase risk[1] are:
- mental workload – stress, reliance on vigilance and memory, seeing what you expect to see and having to calculate complex dosages of medicines.If you have to make complex dose calculations, consider using a pre-calculated list. If available, stock premixed supplies on the ward for high-risk medicines like heparin and potassium chloride.
- distractions – peripheral noise levels or interruptions.Some nurses wear a tabard or apron that says ‘do not disturb/interrupt’ when they do their medicine administration rounds. Setting out distinct areas, for example, using a coloured mat when doing a final medicine check, alerts other staff not to interrupt.
- physical environment – poor lighting, clutter and storage of medicines. Review the lighting in your medicine room – if it is poor, medicines and instructions can be misread. Look at your medicine trolley or room and ask how easy would it be to take the wrong packet or ampoule by mistake or return an ampoule or blister pack to the wrong packet. Consider designating one area of your medicine room to high-risk medicines to highlight that extra care and attention is needed when selecting or preparing these medicines.
- design – devices and products. Medicines with look-alike packaging are common and make picking the wrong medicine more likely. For example, the Humalog® insulins or heparin products. There are also sound-alike medicines, which can make taking verbal orders for medicines harder. For example, azithromycin and azathioprine. How many of the medicines you use have look-alike packaging? How aware are you of sound-alike medicines?
- teamwork – how teams function and communicate can contribute to errors occurring.
Multiple patient handovers, hierarchy and cultures that discourage challenge can all contribute to errors being made. Using briefings and debriefings can help teams develop a shared understanding of a patient or planned procedure. Communication tools like SBAR (situation, background, assessment, recommendation) can help make conversations succinct, and clarify information and expectations of actions required.
Error-prevention strategies should be varied and focus on human factors and system issues. They can include all three leverage strategies, but always choose the strategies that will have a higher impact on preventing medication errors whenever possible.
Join the preventing error and harm webinar on 27 February 2015 to explore system changes and human factors further.
References:
- Implementing human factors in healthcare, Patient Safety First, 2010 accessed at http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-support/Human+Factors+How-to+Guide+v1.2.pdf
