Error Causation “We Need to Write a Policy!!”
Compliance OK – but how can we do the SIGN Now we need OUT if the surgeon I am needed next door to complete has left ? to start the anaesthetic the needle & for the next patient. swab count SOMEONE ELSE can do Sign Out GOAL I need ALL the boxes CONFLICT ticked Sign in Need to check in with my pa to confirm tomorrow’s schedule.. NO TIME for Sign Out Compliance 100% 100% 60%
Causes of Failure • Latent conditions –Organizational failures & systems design –Present in all systems for long periods of time –Increase likelihood of active failures • Active Failures –Errors at the time of the event –Unsafe acts (errors and violations) committed at the “sharp end” of the system –Have direct and immediate impact on safety, with potentially harmful effects
“Active Failures” Routine Reasoned Reckless Violations Malicious Intended actions Rule Based Mistakes Knowledge Based Basic Error Unsafe Types acts Skill based errors Lapses Memory failures Unintended actions Slips Skill based errors Attentional failures
Understanding Optimising violations Personal Gain 85mph 77mph 70mph Life Pressure Illegal-illegal Normal-illegal Legal Perceived Vulnerability Incident* Accident Near miss Belief Expected Systems safe zone Performance Safety
Understanding Optimising violations Personal Gain Normal-illegal Illegal-illegal Legal Very Real Life Policy/ Procedure Unsafe I use non-touch Wash my hands Wash your hands Space technique so when I remember between every or for aseptic patient don’t need to wash my hands technique Incident* Expected Near miss Accident safe zone Performance Safety
Desktop Exercise
Violations and Culture •Normalisation of deviance occurs in systems where there is variation and complexity •Once normalised behaviours/transgressions migrate to extremely unsafe states
Understanding what people have to do to get the job done Baseline performance “Practical drift”
How Does This Happen?
Swiss Cheese Model of Error Causation
Swiss Cheese Model of Error Causation Policies Procedures Technology People
What Motivates Intent?
We would never do something that stupid!
May that’s a one off?
…and Tidy may not be Safer!
Performance Influencing Factors (PIFs) Mental Poor Organisational Ergonomics Memory Perception Complex Systems Communication Stress Concentration Inadequate Poor Knowledge Complacency Awareness Teamwork Education/Training Attitude Motivation Time Pressure Confusing Data Distraction General Health Unavailable or Fatigue Inaccurate Excessive Vision Hearing Skills Procedures Workload Substance Poor Access Medication Size/Agility Climatic Abuse Equipment Conditions Physical Lighting Temperature Noise
The Human Reliability Curve 100% Human Error The ‘Error Zone’ Human Reliability Normal Operation 0% Performance Influencing Factors (PIF’s)
Beliefs About Adverse Incidents Person Centered Approach Systems Centered Approach • Individuals who make errors are • Poor organisational design sets careless, at fault and reckless people up to fail • Blame and Punish • Focus on the system rather than the individual • Remove individual and improve • Changing the system improves quality/safety safety
A Systems Approach • Systems Approach : • Humans are fallible and mistakes are inevitable • The best of people can make the worst of mistakes • Errors are often shaped and provoked by upstream (system) factors • Change working conditions and system to prevent / reduce error • Importance of education and training (The human cannot be trained out of people) • Learn from errors and prevent future errors • Recognise patterns in errors and failures
Add more boxes to be ticked irrespective of the frequency of the error type = Additional complexity and reduced compliance and Increased risk.
Error Reporting
CQC Requirement The Care Quality Commission (CQC) assesses a trust’s speaking up culture during inspections under Key Line of Enquiry 3 as part of the well-led question.
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