Eliminating Human Error in Healthcare

1. Eliminating Human Error in Healthcare

2. Human errors form a significant portion of preventable mishaps in healthcare. Even the most competent clinicians are not immune to it, though it is often associated with unintentionally harming patients. For example, errors in the perioperative period can often have grave consequences, and hence, perioperative clinicians need to be aware of the impact of human errors and train themselves in eliminating human error.

3. While this scenario is common and serious, it’s not the only form of human error that takes place. Human error also happens in administrative roles. And sometimes, the mistakes can be just as damaging as those made in a clinical setting.  In order to improve patient care, healthcare organizations must root out human error in all its forms, whether it takes place on the operating table or in the back-office.

4. Traditionally, errors were attributed to the incompetence of individuals, and emphasis was laid on individual training. This approach is flawed because errors are not always due to incompetence.  This strategy just fixes the blame, not the problem

5. Error prevention should target the cause. Slips and lapses can be tackled by providing optimal training.

6. Properly designed and delivered training to all is very effective in producing certain types of knowledge, skills, and behavior. People don't set out to err. But the use of training and training tools shouldn't be abandoned. Procedures, proper tool use, resource management techniques, techniques to foster communication among team members, reporting systems to identify latent errors, protocols to prevent medication errors, are some of the other strategies that can be adopted at the institutional level.

7. Learning outcomes of Error Prevention training: • Explain the meaning of the term “human factors” • Explain the relationship between human factors and patient safety • Interactions between three interrelated aspects: individuals at work, the task at hand and the workplace itself.

8. For example: we teach cognitive self-monitoring strategies. It’s a technique that helps the clinician to avoid bias or fixation and force them to pause and think. Incorporating sessions on eliminating human error and non-technical skills in gatherings is essential to foster safety culture. Teaching non-technical skills is shown to decrease the incidence of errors.

9. No one is immune to error. Constant vigilance regarding the possibility of error, optimal working conditions, effective utilization of algorithms, mnemonics, checklists, communication aids, and human error training will help in minimizing their incidence.