Enhancing resilience: Medication Error Recovery

In human error, Human Factors, Resiliency on November 13, 2010 at 5:48 pm

How does one reconcile these two statements?
Do no harm.
Errors in heathcare are inevitable.

One current way of thinking involves building resiliency as mentioned in a prior post. One concept in this method is called “error recovery.” One way to study error recovery potential in one’s organization is to study “near misses” and complaints about processes. Although these are traditionally dismissed by some as “not true errors” examining these can help to identify which behaviors or systems are actually preventing harm from reaching the patient despite errors being made. This would be similar to the prevention of falls: we do what we can to eliminate them but assuming falls will always happen we must focus on making any falls injury free.
There are three main steps to error recovery: detection of the failure; identification of deviation and the deployment of countermeasures (Kanse, van der Schaaf, Vrijland, & van Mierlo, 2006). People play a role in recovery due to their knowledge and experience; technology in the design of equipment and workspaces; and organizational factors in terms of work processes, culture, design and management priorities (Kanse, van der Schaaf, Vrijland, & van Mierlo, 2006). There are two types of recovery: planned and unplanned. Planned recovery involves a set of safety steps that everyone knows to initiate like a response to a fire alarm. Unplanned recovery involves more creative thinking, and participants might not know their exact role in minimizing harm.
In order to uncover one’s processes that contribute to or mitigate harm, an organization must create a blame free environment where staff must feel safe to confess mistakes and near misses. The process for investigating near misses might yield more resiliency information than an actual error.
Kanse, van der Schaaf, Vrijland, and van Mierlo ( 2006) describe a method for extracting resiliency or lack or resiliency information from a near miss report. This technique, the critical decision method (an extension of the critical incident technique) involves sitting down and questioning employees in a non-threatening manner. The employee needs to know that any information they can relay can help prevent future harm in the organization. Step one is to ask for a step-by step account of what transpired in terms of step leading to the error and the steps that led to the recovery. This should be done soon after the incident to aid in memory recovery. Questioning should be geared to understanding the behaviors and cognitive action behind steps: how is this possible? What contributes to this? Questioing about recovery steps should also include if the thinking or behaviors behind these steps was something taught by the organization, a standard procedure or something the employee creatively devised.
Kanse, van der Schaaf, Vrijland, and van Mierlo ( 2006) looked at failures on the pharmacy side of the medication process. In their findings, the dominant contributor to failure was organizational culture. There were so many double checks that almost all personnel had minimized their importance as they conflicted with productivity priorities. Particularly lacking was the expiration date check. Many employees lack knowledge of correct doses for many medications but other priorities precluded checking these in detail. There was no procedure to ensure previous checks had been done for prior steps so this failure would not be evident. Another organizational culture issue was the rushing to fill orders was almost expected. Other systems identified were having no notification system to the nursing staff regarding status of orders, a computer system that provided little feedback about incorrect entries and decisions by individual employees whether or not they should report near misses.
One conclusion of this study asks the question of money spent on improving recovery versus the money spent should a major failure occur. Investments in making technology and procedures more user friendly combined with a production system that discourages rushing and allows the human operators more time to think and problem solve are conducive to building resiliency.

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