Monday, January 29, 2007

Error recovery

Ergonomics journal April 2006

'Error recovery in a hospital pharmacy' L Kanse, TW van der Schaaf, ND Vrijland and H van Mierlo

Field study involving confidential reports and follow up interviews on near miss incident where recovery had occurred.

Near misses have the same underlying failure factors as accidents. Sometimes by coincidence but more often by timely detection harm is avoided. Understanding recovery factors offers a way of improving safety in addition to preventing errors in the first place. This is achieved by introducing system characteristics that build in or strengthen opportunities for recovery.

Recovery involves detection followed by a combination of explanation of the causes and putting in countermeasures aimed at returning to normal or at least limiting the consequences.

Although there have only been limited studies they have shown that personal related factors such as experience and knowledge are important in recovery. But also technical factors such as the design of the workplace and equipment interfaces. As well as organisational factors such as culture, work design, procedures and management priorities. In fact the organisational factors may be the most important because they determine the context in which people work and hence are likely to affect other factors.

Planned and unplanned recoveries. Planned involve the activation of in built barriers, such automatic safety controls or procedures that are implemented under certain conditions. Unplanned recovery is more ad hoc and depend on creative problem solving capabilities of the people involved.

The factors that influence planned vs unplanned are likely to be quite different.

Looking at pharmacy errors the study found that procedural checks had started to lapse because people had perceived that so many checks were being carried out that it was too much, and people had become less aware of their importance. Other factors that influenced lack of recovery included management priorities, shortcomings or lack of procedures, insufficient transfer of knowledge and information, technical failures, factors related to the design of computer systems used for medication preparation. With shortcomings or lack of procedures being the most.

On the positive side a lot of the recovery were made by nursing staff, and not the pharmacy staff who made the error. This was down to procedural checks and in some cases where the knowledge of the staff realised something was wrong.

To improve recovery it is important that management make sure everyone understands how important procedural checks are. Near miss reporting systems is a useful way of demonstrating this.

Clearly, there are opportunities to improve procedures. Also, the computer system that could better help detect conflicts in data. Where the severity of errors is great, having double or even triple procedural checks is important, but as not all are forseeable employees must also have the knowledge to detect and recover from problems without the support of procedures. Special training may be needed using problem scenarios inspired by reported near misses to maintain everyones creative problem solving skills.

Andy Brazier

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