Healthcare errors which jeopardize patient safety are not rare. Majority of these errors are mainly caused by human factors, but a small percentage can be attributed to technological factors; this is mainly because humans are generally prone to committing mistakes. The fallibility of human beings is aggravated in cases where the individual is distracted, stressed, tired, overworked, or frequently interrupted (Dekker, 2016). Human factors are an essential part of the healthcare system and have been a subject of research, numerous reviews, and subsequent reforms.
This paper discusses human errors in cognitive or thought processing giving a specific real-time example of a death at a nursing home which was subject of a coronial inquest; it was suspected that an error in medication could have been the cause if the death. This paper uses this example to present some strategies and approaches developed after research of human factors in the healthcare sector, which, if implemented could reduce the frequency of similar cases.
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The Case
A nursing home in Australia was the subject of a coronial inquiry aimed at investigating a death at the medical facility. The investigators found that even though the cause of death had been recorded as natural death, and no individual had directly or indirectly contributed to the death of the patient, it was proven that an error in medication had occurred during the hours before the death of the patient (Gluyas & Morrison, 2014). The inquiry team established that the patient had received a subcutaneous shot of 25 milligrams morphine instead of the prescribed 2.5 milligrams. The inquest further established that the medical practitioner involved was a new graduate nurse who was on her third shift as a practicing nurse at the medical facility. The new graduate had not undergone the required two-day orientation (which is popularly known as ‘buddying’) which is mandatory for all new staff at the facility. When the incident happened the nurse in question was on duty, with three other nursing assistants working under her. Under her attention, there were a total of 36 patients in the nursing home, 17 of whom required specialized care (Gluyas & Morrison, 2014). The inquest observed that the care of one patient required a considerable degree of attention from the graduate nurse which mainly involved rigorous interaction with other medical practitioners within the medical facility; this, the report continued, resulted in lots of mental pressure and time constraints as the nurse worked hard to cater to the needs of all patients under her care (Gluyas & Morrison, 2014).
Implications and Responses
The death of a patient due to human error is usually a bad element in the reputation and public image of any medical facility. Such cases can potentially lead to litigation processes, which are quite costly, jail terms and fines for the culpable parties, loss of patient confidence and loyalty and damage to the image of the facility. In the case described above, the healthcare leaders initially tried to downplay the magnitude of the incident (fancy words to describe a cover-up) so as to avoid the legal implications and other blowbacks involved (Gluyas & Morrison, 2014). The nurse involved was understandably very devastated; it’s not easy for any medical practitioner to fathom the fact that they potentially caused the death of a patient.
However, the external stakeholders, including the public sector (led by the relatives of the deceased), demanded answers and eventual justice for any wrongdoings involved. It was after a few demonstrations outside the premises of the nursing home that the management agreed to invite an external and independent inquiry to investigate the issue and recommend appropriate actions for any wrongdoing.
The report of the inquiry concluded that there was a human error in the administration of medication; however, it cleared the nurse of any wrongdoing putting into consideration her inexperience and the pressures she was under during her shift (Gluyas & Morrison, 2014).
Recommendations
The most effective strategies to reduce human errors should be to design procedures, systems, technology, and working environments that are can recognize human shortcomings (Fryer, 2012). One of the recommendations is to avoid relying on human memory; protocols and systems should be put in place requiring medical professionals to check their knowledge and tasks regularly. Such systems and resources can either be in written or technological forms. Additionally, the nursing home should encourage the use of such resources and make it part of their culture. Visibility is another strategy to reduce errors due to human factors. The nursing home should adopt diagrams and posters which are highly visible detailing the procedures and processes necessary for various tasks (Fryer, 2012). In our case, a poster depicting the correct dosage of morphine should have reminded the nurse to avoid the overdose.
Lastly, the use of frequent briefings, checklists, and verbal double-checking protocols can mitigate human errors in nursing practice. However, Beaumont & Russell (2012), argues that checking procedures are only useful when undertaken with utmost caution and attention. If they are embarked routinely and in an automatic way, they can be susceptible to lapses and slips which are common in automatic human processes. It is vital for medical practitioners to prioritize the safety and wellbeing of their patients above all else. Safe, and exceptional quality procedures should be adopted to ensure that this goal is attained. Concurrently, the health of a vast number of individuals would be improved.
References
Beaumont, K., & Russell, J. (2012). Standardizing for reliability: the contribution of tools and checklists. Nursing Standard (through 2013) , 26 (34), 35.
Dekker, S. (2016). Patient safety: a human factors approach . CRC Press.
Fryer, L. A. (2012). Human factors in nursing: The time is now — Australian Journal of Advanced Nursing, The , 30 (2), 56.
Gluyas, H., & Morrison, P. (2014). Human factors and medication errors: a case study. Nursing Standard (2014+) , 29 (15), 37.
