Accident prevention in surgical settings—keeping patients safe - Research Corner

AORN Journal,  Feb, 2002  by Suzanne C. Beyea

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Organizational factors (ie, flawed systems) contribute to medical errors and adverse events in surgical settings. To date, little research has focused specifically on preventing errors in the OR. Leading patient safety experts propose that clinicians apply cognitive psychology and human factors principles to reduce errors and prevent accidents. (1) By understanding how cognition and error mechanisms apply to health care systems and processes, clinicians can

   examine their care delivery systems in terms of the systems' ability to
   discover, prevent, and absorb errors and for the presence of psychological
   precursors. (2)

Aviation and other industries have created a culture of safety and decreased the likelihood of errors and their potential effects by applying these same approaches.

ERRORS

In describing the "central law of improvement," one health care improvement expert tells health care clinicians that "every system is perfectly designed to achieve the results it achieves." (3) Complex systems, such as health care, appear to be more prone to errors than others. In aviation, a primary focus on safety has led to systems that are designed to minimize the risk of errors and accidents and limit damage if errors occur. In health care, safety frequently has been espoused but has not been the central focus when new processes are designed or implemented.

Experts recognize that health care is an extremely complex system comprised of numerous equally intricate components that are likely to interact with multiple other parts of the system in unexpected ways. Complex systems reflect high levels of specialization and interdependency among their various components. They are at high risk for accidents and must be made more reliable. (4) Most experts agree that errors occur as the result of multiple small factors, and it is only when these factors combine that an adverse event occurs. Simplifying and standardizing processes, back-up systems, organizational design, and team performance can contribute to system reliability and, thus, fewer errors and adverse events.

Psychological precursors or preconditions (ie, factors that intervene between a system's design and the production process) can create conditions for errors. (5) Safe and efficient practice requires, at a minimum, a skilled and knowledgeable workforce; the right equipment, which is well-maintained and operates reliably; efficient job design; reasonable work schedules, stress levels, and environments; and clear performance guidelines. Technology, hardware, software, equipment, medications, and procedures should be considered integral components of the health care environment. Technology may automate processes and minimize risks, but it also may increase system complexity and the risk of error.

For technology to be used safely, it should be designed according to human factors principles.

   Human factors is defined as the study of the interrelationships between
   humans, the tools they use, and the environment in which they live and
   work. (6)

Human factors analysis is the study of human performance and the process of error, its causes, circumstances, conditions, and other associated factors. The primary focus when implementing human factors principles is improving human-system interfaces by designing better systems and processes.

In health care, a better understanding of the factors and circumstances that lead to errors and adverse events must be gained. Clinicians should question things such as the reasons wrong site surgery occurs and how human factors research can lead to improvements that minimize inherent risks in existing systems.

ERROR-REDUCING APPROACHES

One patient safety expert suggests some approaches that can be used to redesign health care delivery systems to reduce error risks. (7) These approaches include

* reducing reliance on memory,

* improving information access,

* incorporating error proofing,

* standardizing processes, and

* training employees.

To reduce reliance on memory, this safety expert suggests using checklists, protocols, and computerized decision aids. Improving access to information could be achieved by computerizing patient records. Error proofing could be incorporated by using computerized tools that prevent a physician from ordering a medication if the patient is allergic or if the dose is inappropriate or lethal. An example of standardization, which increases efficiency and reduces error potential, is standardizing medication doses and administration times. The incidence of adverse events can be reduced further by training clinicians about the potential for errors and how to prevent them.

WRONG SITE SURGERY

Consider the incidence of wrong site surgery. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently published a sentinel event alert regarding significant concerns related to wrong site surgery. (8) This report is a follow-up to an August 1998 alert regarding the same problem. The recent report addresses concerns that, despite national attention and efforts by professional associations and regulatory groups, the incidence of wrong site surgery remains extremely high.