Systems Analysis of Errors

Debora Simmons, PhD, RN, CCNS

What is a Systems Approach?

Humans are fallible and errors are to be expected, even in the best organizations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in "upstream" systemic factors.

Reason, 2000

What is a System?

A set or group of interacting, interrelated or interdependent elements or parts that are organized and integrated to form a collective unity or a unified whole to achieve a common objective

Reason,1990

Systems of the body

Interdependent – lung-heart- kidney Interactive –vascular-heart-kidney

Active : Occur at a set point and consequences are readily apparent

Latent Errors- Are delayed reactions and are consequences of decisions made away form the point of impact

System Failures

James Reason

B James

A Path to Failure

Latent Current Active

Failures Conditions Failures DefensesACCIDENT

Cognitive Failures (Memory Lapses)

Slips

Mistakes

Workload

Equipment

Knowledge

Ability

Environment

Manufacture Design

Management Decisions

Policy

van der Schaff- modified for healthcare

Technical

Organizational

Human Factors

Adequate defenses

Return to Normal

Developing Errors

Near Miss

Dangerous Situation

Dangerous Situation

ERROR(Inadequate

Defenses)

ERROR(Inadequate

Defenses)

The Cause and Effect Principle

#1 Cause and Effect

Cause and effect are the same thingDiffer by how we perceive them in time

Effects Causes

Injury Caused By Fall

Fall Caused By Wet Surface

Wet Surface Caused By Leaky Valve

Leaky Valve Caused By Seal Failure

Seal Failure Caused By Not Maintained

#2 Cause and Effect

Cause and Effect are part of a continuum of causes A Primary Effect is the effect of a consequence that we want to prevent from occurring

CBCBCBCBCBInjury Fall

Wet Surface

Leaky Valve

Seal Failure

Not Main-tained

Cause and Effect # 3

Each effect has at least two causes in the form of actions and conditions Actions are momentary causes that bring conditions together to cause an effect

Conditions are causes that exist over time prior to an action

Primary Effect

Action

Condition

By

Cause and Effect Principle #4

An effect exists only if its causes exist at the same point in time and space

You have to have: the action and the conditions

Cause and Effect Principle # 5

There is never one cause

Problem Solving Using C/E

Identify causal relationships and control one or more of the causes to affect the problem in a way that meets the objectives

Understand the problem Use an effective tool set

Classic

If people are more

careful,

pay attention,

are more detailed

there will be a

decrease in errors

(My Mother)

New

It is the design of

objects,

activities,

procedures

patterns of behavior

that result in error

Norman and Reason

Human Factors Analysis

Properties of Memory

Decision Making

Information

Environment

Physical

Error is Inevitable Because of Human Limitations

Limited memory capacity Limited mental processing capacity Negative effects of stress - Tunnel vision Negative influence of fatigue and other

physiological factors Limited ability to multitask Flawed teamwork

Systems of Care

> 80 % medical error is system derived 95 % of mistakes are made by the good guys like

you and me Finding the “Bad Apples” and fixing them doesn’t

work – there aren’t enough The system solution – make it hard to do the

wrong thing

Nurse inadvertently connected a feeding of expressed breast milk to an intravenous line

IV tubing connected

Connector for NGT ( feeding tube)

Connector for NGT (feeding tube) connected

IV tubing

IV tubing connected

Connector for NGT (feeding tube)

Syringe used for feeding

Syringe Pump used for IV infusions and Feeding through NGT

27

29

Central Venous Catheter

Gastrostomy TubeArterial Catheter

Epidural Catheter

2/7/00

Literature Search

First documented misconnection – 1972 (Wallace)

© 2006 Simmons & Graves

Joint Commission Institute for Safe

Medication Practices Food and Drug

Administration American Nurses

Association

American Association Medical Instrumentation

- 1996 and 2005

International Standards Organization

World Health Organization

California Bill 2013 deadaline

ADvaMED

Tubing misconnections

A review by USP of more than 1200 cases: Intravenous infusions connected to epidural lines, and epidural solutions (intended for

epidural administration) connected to peripheral or central IV catheters.

Bladder irrigation solutions using primary intravenous tubing connected as secondary

infusions to peripheral or central IV catheters.

Infusions intended for IV administration connected to an indwelling bladder (foley)

catheter.

Infusions intended for IV administration connected to nasogastric (NG) tubes.

Intravenous solutions administered with blood administration sets, and blood products

transfused with primary intravenous tubing.

Primary intravenous solutions administered through various other functionally dissimilar

catheters, such as external dialysis catheters, a ventriculostomy drain, an amnio-infusion

catheter, and the distal port of a pulmonary artery catheter.

Tubing Misconnections: Normalization of Deviance

Debora Simmons, Lene Symes, Peggi Guenter, and Krisanne Graves(Nutr Clin Pract. 2011;26:286-293)

Case reportsN =116 Adult (N=60)Child/infant (N=30)Not Specified (NS) (N=26)

Patient Outcome from 116 casesDeath (N=21) Survival:

Hypersensitivity and Hypercoagulopathy reaction (N=1)Septicemia/sepsis (N=16):

2 with neurologic damage2 with respiratory arrest33 with hypoxia1 with seizure & hypoglycemia5 with intracranial hemorrhage

Renal impairment (N=8)Respiratory arrest/distress (not listed above) (N=2)Neurologic damage (not listed above) (N=2), 1 with blindness & deafness

No harm, or outcome not given (N=12)

Enteral to Respiratory or Respiratory to Enteral

Majority = Blood pressure monitors to Intravenous lines

Gas to Intravenous line

Infusion and monitoring systems in healthcare are physiologically not compatible – many cause death if accidently connected to another

Infusion systems rely upon a single, universal connector- the luer tip/small bore connector

Routine tasks such as connecting tubing are at risk for “automatic mode errors”

Connecting Tubing - a high risk activity

Nurses’ Understanding of Tubing Misconnections between Enteral and Intravenous Systems: a

multiple case, explanatory, grounded theory study

July 6, 2011

What do nurses understand about tubing misconnections between enteral

and intravenous systems?

NURSES UNDERSTANDING OF TUBING MISCONNECTIONS BETWEEN ENTERAL AND INTRAVENOUS SYSTEMS

COGNITIVE CONSTRUCTS HUMAN ABILITY

KNOWLEDGE AND EXPERIENCE

ATTENTION CONTROL

EMOTIVE AND PHYSICAL

FACTORS OUT OF CONTROL OF THE NURSE IMPROBABILITY OR PROBABILITY

FATE

CHARACTERISTICS OF THE NURSE PATIENT or FAMILY

TECHNICAL PROPERTIES LABELS

LOCATION OF TUBE

PHYSICAL ATTRIBUTES PUMP, CONNECTOR AND SYRINGE

COLOR AND CONSISTENCY OF FLUID

WORK ENVIRONMENT LIGHTING

CHAOS

SHIFT CHANGE

POLICIES, SUPPLIES AND COST

Findings Cognitive Constructs Nurses have a wide variation in their knowledge

regarding the occurrence of tubing misconnections.

Limits on human ability, factors that nurses cannot control, and characteristics of the nurse, patient, and family may contribute to tubing misconnections.

Findings

Work Environment Multiple organizational practices do not support the

mental work of nurses. Healthcare has not applied common safety concepts to

the work environment.

Technical Properties Some nurses rely on physical attributes of attributes of

devices to cue them to make tubing connections. Others report that relying on such cues may lead to misconnections.

Future Research Cognitive Constructs Nursing education research : How do you imbed generic safety

knowledge within the nursing workforce? How can we improve human (nursing) ability to provide safe and

effective patient care in the face of complexity in healthcare?

Work Environment How can the work environment and organizational practices be

modified to support the work of nurses?

Technical Properties How do nurses’ attach meaning to common medical devices and

tasks? What design features of healthcare devices support nurses’ cognitive

work?

“This label has a good purpose.”

“This label is stupid.”

Variation in Understanding safety

Overarching Conclusions Nurses do not conceptualize making a tubing

connection as a linear process. Nursing has not assimilated basic safety principles

into practice. Factors related to the cognitive constructs of

nurses, the work environment, and technology properties are pervasive and create an environment that may be deadly for patients.

Human Factors the study of interrelationships between humans, the tools they use, and the environment in which they live and work

Used to design safer and more effective systems Commonly used in industry

(aviation,nuclear,chemical,production) Used in critical incident analysis

- 9/11, Chernobyl, Challenger, Three Mile Island

Human Factors

Cognitive Behavioral Individual Industrial Organizational Cultural

How do we make healthcare

errors?

Cognitive Psychology :The way we think and problem solve 1) Planning - gather information2) Storage – process information 3) Execution – make a decision

Memory Ability to store, retain, and subsequently

recall information Three main stages in the formation and

retrieval of memory:– Encoding (processing and combining of received information)

– Storage (creation of a permanent record of the encoded information)

– Retrieval/Recall (calling back the stored information in response to some cue for use in some process or activity)

Sensory Associations to Memory

Tying ribbon or string around a finger is the iconic mnemonic device for remembering a particular thought, which one consciously trains oneself to associate with the string.

Error Modes

Automatic ModeSlips Lapses

Non Automatic ModeMistakes

Automatic Mode –the state of mind where familiar actions take place effortlessly

Unconscious actions Are frequent in common familiar tasks Can not be escaped

Automatic Mode:

Slips- errors that occur during familiar actions and are governed by familiar impulses incorrect execution of a planned action occur when you automatically do something that you didn't mean to do

(Locking the keys in the car)

Habit Interruptions Hurry Fatigue

Anger Anxiety Boredom Fear

Causes of Slips and Lapses

Please comment

FDA Issues Feeding Tube Misconnection Guidance Document

To help combat the deadly problem of tubing misconnections, the U.S. Food ... manufacturers weigh the risk of small-bore connectors for enteral feeding tubes.

www.aami.org/news/2012/073012_connector.html

Van Der Shaf- modified for healthcare

Technical

Organizational

Human Factors

Adequate defenses

Return to Normal

Developing Errors

Near Miss

Dangerous Situation

Dangerous Situation

ERROR(Inadequate Defenses)

ERROR(Inadequate Defenses)

Managing Risk – The Three BehaviorsDavid Marx

Reckless Behavior

Intentional Risk-Taking

Manage through:

Disciplinary action

At-Risk Behavior

Unintentional Risk-Taking

Manage through:

Understanding our at-risk behaviors

Removing incentives for at-risk behaviors

Creating incentives for healthy behavior

Increasing situational awareness

Normal Error

Product of our current system design

Manage through changes in:

Processes

Procedures

Training

Design

Environment

Ooppps!!!!!!