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Identifying Vulnerabilities in Standards Compliance, Methods to Improve Performance

By Laura Gayton

Understanding human factors and compliance go hand-in-hand when it comes to striving for patient safety within health care organizations. Compliance is often based on how an organization lays out its critical safety information, processes and procedures. Establishing a clear set of instructions, standardized language and written procedures allows staff to complete processes and maintain consistency. In addition, such processes provide the greatest opportunity for best practices to be followed and procedures to be successfully completed. However, human factor considerations continue to be leading vulnerabilities affecting performance improvement.

David Mallard from Environment Health and Safety Today explains that understanding the impact of health care safety errors requires understanding human factors, inherent behaviors, characteristics, needs, abilities and limitations. In addition, it requires the study of developing sustainable and safe working cultures.

Where there are humans, there inevitably will be human error – it is impossible to eliminate human error entirely. However, by using strategies such as checklists to document and guide tasks helps to limit the occurrence of human error from becoming a real problem at health care organizations. An example of stellar use of checklists can be observed from the airline industry. Use of a pre-flight checklist is imperative to a safe flight. Simply put, a pre-flight checklist consists of tasks that a pilot and/or crew must perform prior to takeoff. The checklist is specific and can be arranged in sequential or segmented order. The concept of pre-flight checklists evolved in 1935 after a fatal crash involving a Boeing test pilot. The investigation revealed that aircrafts require too many complex preparations for a pilot’s memory to recall. It was unrealistic to rely on his or her memory for all flight preparation tasks that must be completed prior to flight. The solution was creating and completing a complete pre-flight checklist.

Similarly, in 2007 the World Health Organization (WHO) developed and implemented the WHO Surgical Safety Checklist. Like the limitations of a pilot’s memory who depends instead on a pre-flight checklist, a perioperative team member would also rely on a pre-operation checklist to complete tasks prior to a surgical procedure. The WHO checklist was developed to enhance communication between a surgical team member, improve outcomes, decrease complications and improve patient safety.

Consider the operating room (OR), a complex environment that contains staff, equipment, alarms, computers, and sometimes ringing telephones. Multi-tasking between patient, the surgical team and procedures in the OR (e.g. set-up, counting, specimen management) involves simultaneously meeting a plethora of competing priorities. The effects of distractions during a surgical procedure are physically and cognitively demanding and perioperative team members must maintain a state of constant situational awareness. The attention of the circulating nurse is pulled in various directions. So, it may be challenging for a health care organization to identify these vulnerabilities to maintain safety and compliance. The Surgical Safety Checklist makes it easier to identify distractions and document procedures.

Reviewing how human factors affect the workplace begins with reviewing the task. Consider the timeframe during a surgical wound closure and time allotted for accounting for instruments, sponges and needles. Since there are multiple tasks to be accomplished and a critical need for accuracy, the demand on a health professional’s workload makes him or her vulnerable for error. The working environment of the operating room includes noise and distractions from surgical display alarms and equipment controls. These distractions make clear communication within the surgical field imperative. Communication breakdown may be associated with surgical site infections with this increased movement around the surgical field.

So, how can an organization limit vulnerability? It is important to first limit the distractions. A recent Association of PreOperative Registered Nurses (AORN) position statement on managing distractions and noise during perioperative care endorses a multidisciplinary team approach to reducing distractions and creating a safer OR environment. The document explains that while keeping OR noise to a minimum, especially during critical phases of surgical procedures, a surgical team should create a no-interruption zone in which non-essential activities are prohibited. Non-essential activities should be clearly identified prior to surgery, and any intervention needs to be adaptable and practical to the team.

By limiting distractions, the human cognitive workload is also reduced. Workflow functionality should aim to be seamless and offer few disruptions, supporting the idea that standard work and workflow processes can greatly reduce error. Increasing situational awareness to critical phases and eliminating cognitive biases help staff witness what they are expecting to see. Decreasing or eliminating sources that cause error or enable safety issues helps to reduce human error and vulnerability and makes the environment safer. For example, using unique barcode scanning technology increases the reliability percent accuracy for sponge identification used during surgery.

Health care organizations can incorporate identifying human factor vulnerabilities within their commonly used analysis methods. Root cause analysis is a structured analytical tool used to address surgical errors after they occur. Failure mode and effects analysis (FMEA) is a useful process to identify and address potential problems and their effects before an adverse event occurs. By using these methods, health care organizations can evaluate systems and processes with human factor considerations in mind to effectively identify vulnerabilities and implement human factor-based solutions that ultimately promote safety and mitigate risk.



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