Safety: focus on the details ¹

Article Outline

• Risk patterns
  • Rushing
  • Frustration
  • Fatigue
  • Complacency
• Critical errors
• References
• Copyright

SAFETY, OR BEING FREE FROM HARM, is important in every environment, yet it is also a very personal issue. Most of us take many routine actions each day to keep ourselves and our loved ones free from harm. We have smoke alarms in our homes. We lock our doors to keep out intruders. Many of us activate alarm systems when we are both in and out of our homes. We make sure to turn off all appliances before leaving for work. We buckle up in the car and lock the doors. Our children must ride in the appropriate-sized car seat or restraining device. We babyproof or childproof our homes as appropriate.

Our quest for safety does not end when we leave our homes. Most of us try to be constantly aware of our environment when we are out and about. We park in well-lit areas and always try to travel with a buddy. We try to be aware of what is going on around us and listen to our gut or our inner voice. We teach our children never to talk to strangers or get close to a strange car. And that does not count all of the “look both ways” before you cross the street, always wear your helmet while riding your bike lectures! We take so many “extra” steps and precautions to stay safe, yet we sometimes fail to pay attention in the routine, everyday tasks and activities that we muddle through both in and around our homes and work.

I have always heard that most car wrecks occur within a 3-mile radius of your home. Think about it! If you have ever been in an accident, or just a mild “fender bender,” were you fairly close to home? We always worry about the long road trips, but in truth, it is the daily runs to work, school, soccer practice, and the grocery store that pose the most risk. Why? I think it is because these short trips are routine. We know the way, the roads, and the landmarks. Therefore, we feel comfortable to “multitask” while driving. We talk on the cell phone or carry on conversations (and sometimes arguments) with our children or spouse. We go through the plans for the day while on the way to school. You know the routine…this is where mom is working today, this is who will pick you up, make sure to have your homework done by the time mom gets home from work, and oh, let me call out those spelling words one more time to make sure that you know them! Do you see yourself in any of these scenarios? The reality is that 90% of car wrecks are caused by driver error and/or distraction.1

Are things any better when you get to work? We follow a lot of rules and protocols to protect ourselves and our patients from harm, but the reality is that despite our efforts, 44,000-98,000 deaths occur in U.S. hospitals each year due to medical errors.1 And most of these errors can be traced back to unintentional, individual mistakes that no one ever intends to make. Regardless of the systems in place, we, as humans, tend to multitask, to become distracted, and to make mistakes. And those mistakes, particularly in the health care environment, can kill.

A basic awareness of one’s weaknesses and risks for making mistakes in our everyday activities, however, can do wonders for preventing errors both at home, and in the workplace. Everyone has common basic risk patterns that can lead to critical errors.1 An awareness of these patterns and potential errors is the key to preventing errors and accidents from occurring.

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Risk patterns 

The Safestart program by Primedia Workplace Learning lists four basic states that create risk patterns for almost all injuries and errors, both in and out of the workplace.1 Unfortunately, in today’s rapid paced environment these patterns are far too common.

Rushing 

Rushing almost always leads to some type of error. When we are running late and rushing out of the house, we tend to forget things. Or we back into the trash can at the end of the driveway, or we get a speeding ticket on the way to our destination. Or we take a rolling stop at the stop sign and run right into the path of an oncoming 18-wheeler.

Rushing at work can lead to similar errors. We send someone home without the appropriate teaching or prescriptions. We rush them up to the floor, only to find that they have to return to surgery an hour later for complications. We rush to get the case started in the OR, only to find that we have rushed to operate on the wrong side.

Frustration 

Frustration leads to anxiety, and anxiety always decreases one’s ability to focus. It is somewhat like “Murphy’s Law.” Once one thing goes wrong, everything goes wrong. And the day goes downhill from there. Be aware that frustration will lead to a lack of concentration, thus more errors and further frustration. When at all possible, try to remove yourself from the situation long enough to take a deep breath and refocus.

Fatigue 

Fatigue is probably every nurse’s worse enemy. Fatigue is inherent in a job with long hours, multiple shifts, call, and lots of physical labor. Fatigue also leads to stupid mistakes such as drug miscalculations. Be aware of your own energy levels. Ask for relief when you are fatigued to the danger level. Know your limits.

Complacency 

Complacency is what gets us in trouble with the day-to-day routines and simple patients. We “do this all the time” and therefore, we don’t worry about making a mistake. We don’t think and go into automatic pilot. And then we don’t pay attention to detail, and we get in trouble.

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Critical errors 

The above risk patterns can lead to three major critical errors that can result in minor and major mistakes both at home and in the workplace. These critical errors are1:

Eyes not on task and mind not on task are somewhat interrelated. Essentially, you are not paying attention to what you are doing, saying, seeing, or hearing. It can be something so simple as going to the grocery store intending to buy a diet soft drink, only to get home and discover that you picked up the regular “full-sugar” variety. You read the label, but did you “really” see it? Or you are listening to your child, but you don’t “really” hear them, and end up agreeing to host the team Valentine’s party. Or you reach in the blood refrigerator and pull out Mr. Jones’ O positive blood instead of Mrs. James’ O negative that you intended to get. There is no intent to harm, but the potential for harm and possible death is there.

Let’s take the blood scenario a step further. You are probably saying to yourself, “Yea, but if I pick up the wrong blood, we would still catch that in the final check before we hang it.” Ok, add the last critical error: put yourself in the line of fire. You know you have been there. I forgot to tell you that Mrs. James is bleeding out. All you know what has broken loose and you are hanging blood as fast as you can get it. So you get the wrong blood, you hand it to another nurse (who, by the way, does not have their glasses on), they see the big “O,” think they see “negative,” everybody is yelling, and they hang the blood. The next thing you know, Mrs. James reacts with a full-blown blood transfusion reaction and dies. Did you intend to get the wrong blood? No!! Did your coworker intend to hang the wrong blood? Absolutely not! Did anyone come to work that day with the intention of killing a patient? No…but it happened.

Eyes not on task, mind not on task, and being in the line of fire. All critical errors presenting as simple mistakes. The combination, however, is deadly. I once heard that every accident, regardless of how minor, has a human enabling factor somewhere up the line. Someone, somewhere, fails in some simple task, and the day’s mail gets delivered to the wrong address, or the plane crashes during takeoff. Regardless of the policies, procedures, and safeguards that are put in place, they are only as effective as the individuals who write them, and more importantly, carry them out.

It only takes one weak link, one moment of inattention, to cause an error. Be aware of the common risk patterns as they present in your day-to-day activities, and adjust and compensate for these weaknesses when they present. Pay attention to details. And when the crisis presents and you are in the line of fire, be supervigilant because such scenarios are when all critical errors are most likely to culminate in a serious event. Safety is everybody’s business. Be aware. Be smart. And focus on the details.

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References 

1. Media Workplace Learning: Safestart healthcare: The patient safety training solution. 2003; Available at www.pwpl.com/healthcare/safestart/. Accessed December 15
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• 1 The ideas or opinions reflected in this editorial are those solely of the author and do not necessarily reflect the opinions of ASPAN, the Journal, or the Publisher.