Mistakes in Health Care : The Science of Errors

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• Convert more complex tasks to simpler tasks when possible

• Reduce the overall number of tasks when possible

• Identify and minimize drift

• Limit cognitive load

How To Reduce Errors In Four Simple Steps:

Complex Systems Error

https://www.theguardian.com/film/2017/feb/27/pricewaterhousecoopers-issues-sincere-apology-for-oscars-blunder

Tasks of different complexity have different error rates

Situation Task Type Error Rate

Can I fill a bathtub without spilling water over? Simplest Possible Task 1 in 10,000

Can I correctly set an on/off switch to the right value? Routine Simple Task 1 in 1,000

Can I correctly choose from a vending machine? Routine Task with Care Needed 1 in 100

Can I do an unfamiliar or emergency task correctly? Complicated Non-Routine Task 1 in 10

Smith, DJ. Reliability and Maintainability and Risk. Appendix 6, 7th Edition, Elsevier, 2005

Complex Systems Error

Assistant #1 Presenter

Complex Systems Error

Assistant #1 Presenter Assistant #2

Complex Systems Error

Simplest Possible Task(hand the top one)

Simplest Possible Task(read it)

Assistant #1 Presenter Assistant #2

Complex Systems Error

Simplest Possible Task(read it)

Routine Task with Care Needed(hand or discard the top one)

Assistant #1 Presenter Assistant #2

Routine Task with Care Needed(hand or discard the top one)

Complex Systems Error

Complicated Non-Routine Task(make correct emergency decision)

ERROR

Assistant #1 Presenter Assistant #2

Routine Task with Care Needed(hand or discard the top one)

Routine Task with Care Needed(hand or discard the top one)

Task Frequency Increases Chance Of Error

Do it once: .9999Do it twice: .99992 = .9998 Do it 10 times: .999910 = .9990 Do it 1000 times: .99991000 = .9048

Task Frequency Increases Chance Of Error

Drift Increases Chance Of Error

• Driving 5-10 miles per hour over the speed limit

• Carrying a cell phone, a notebook, and a coffee cup

• Skipping step 4 of a 10 step process since “nobody does it”

• Entering a room with the medications for two patients in two hands

Human Error

Product of system design & behavioral choices

Change . . .• choices• processes• procedures• training• design• environment

Console

At-Risk Behavior

ChoiceRisk believed

insignificant or justified

• Remove incentives for at-risk behaviors

• Create incentives for healthy behaviors

• Increase situational awareness

Coach

Reckless Behavior

Willful disregard of substantial &

unjustifiable risk

• Remedial action• Punitive action

Punish

14

Just Culture and Drift

Working Memory and Cognitive Load

http://theelearningcoach.com/learning/20-facts-about-working-memory/

Working Memory and Cognitive Load

• Convert more complex tasks to simpler tasks when possible

• Reduce the overall number of tasks when possible

• Identify and minimize drift

• Limit cognitive load

How To Reduce Errors In Four Simple Steps: