A woman arrives at a hospital to give birth. She has a strep infection and is prescribed penicillin to be delivered by IV to prevent the infection from spreading to the baby. She also asks for an epidural for pain control. The nurse retrieves the epidural bag and sets it on the counter next to the patient. Soon after, the penicillin bag arrives and is set down next to the epidural bag. The nurse prepares to administer the penicillin and accidentally takes the wrong bag, administering the epidural analgesic (intended for injection into the spine) into the patient’s bloodstream. Soon after the patient goes into a seizure and dies later that evening.
Was the nurse negligent?
To answer this question, it is useful to understand what may have really caused the error. Did it occur because the nurse was fatigued as a result of taking on an extra shift? Or was it because she was also caring for five other patients and was expected to remember too much information at one time? Or was it because the two tasks she was doing were so similar that she became confused? Shift rotation, short-term memory demands and task patterns are but a few well-known factors that shape how well humans perform in the workplace. Knowledge of such factors can be used to prevent such errors from occurring.Human Factors is a branch of applied science practiced by psychologists, engineers, and anthropologists that applies information about human abilities, limitations and characteristics, to the design of devices, systems, job tasks and environments to enhance human performance.
Until recently, human factors practitioners have not been indigenous to hospitals. This is quickly changing with the introduction of the Healthcare Human Factors Group (HHFG) at the University Health Network (UHN). The HHFG is the first team of human factors experts employed by a hospital and will begin training staff to be more aware of human factors issues in their work environment. The HHFG is offering half-day courses for UHN clinical staff so they can help identify human factors issues that have the potential to negatively impact patient safety in their work environment. Most patient safety efforts to date have been in response to major incidents or near misses. Health-care organizations are trying to prevent reoccurrences of known adverse events. However, there are many potential errors that have yet to be discovered, and by teaching clinical staff about human strengths and limitations, they can play an important role in helping to identify these hidden errors before a patient’s safety is compromised.
One of the expected outcomes of the course is that clinicians will see their work environment differently. They will question why a task is difficult. They will be able to identify environmental elements, the order in which they are expected to do things, or the workload they are carrying as contributing to the problem, before they put the blame on themselves. By observing potential systemic factors, they may help to uncover a poorly designed device, process, or environment.
The Healthcare Human Factors Group is also involved in a number of other patient-safety related activities. Using the Centre for Global eHealth Innovation’s state of the art usability laboratory at UHN, they are able to create realistic health-care settings where even the most complex software and hardware systems can be studied without compromising the quality of information gathered or patient safety. Using this facility, the HHFG helps to evaluate medical devices to inform purchasing decisions, works with the hospital to identify policies and establish work practices that can positively impact efficiency and safety, and works with information systems designers to ensure that medical information systems are easy to use and reflect the needs of all clinicians who use them.
The Canadian Adverse Events Study published in 2004 in the Canadian Medical Association Journal points out that there is much work to be done to reduce the 9,000 – 23,000 deaths that occur in Canada each year from preventable medical error. Applying a human factors perspective to health-care delivery is a big step forward towards improving patient safety and the work environment for health-care practitioners. For more information about how human factors practitioners can improve safety efforts at your hospital visit www.humanfactors.ca.