An error trap is a situation that could lead into avoidable harm if not mitigated. It is a situation where the circumstances in combination with human cognitive limitations make errors more likely. Error traps can be found throughout health and social care in medicines, equipment and devices, in documentation, and in many other areas we see every day while going about our daily jobs in health and social care.
We want to raise awareness of these error traps on the hub but more importantly we want to hear your suggestions of what needs to be done to prevent them and examples of where action has been take and worked. View our error trap gallery and share your examples.
How many times have you been to the drug cupboard/trolley at work and looked at it with despair?
How many times have you looked at a written prescription or plan of care and were unable to read the writing?
How many times have you gone into the storeroom and spent ages looking for what you want as everything looks the same or it has moved to a different spot?
These are what we call error traps. It is as if you have an annoying brother/sister that is trying to catch you out! Sometimes in healthcare, no matter where you work, there are times when it is not easy to do the right thing. Often, we know about these traps and have become used to living with them. We may set up processes that mitigate us making the mistake.
This is great, but is this addressing the problem? We have diagnosed the problem, but we haven’t stopped that potential error from happening again.
In the world of ergonomics it is the forcing function commonly cited in human factors case studies as recommendations for error-prevention in health and safety contexts. It means forcing users to do something in a certain way in order to proceed on a journey.
A great example is how banks have prevented customers from leaving their card in the ATM. The forcing function is that the machine will bleep to prompt the customer to remove the card from the machine before the money is released. This prevents cards being left in the machine. Whereas if there was just a sign saying ‘remember to take your card’ there will always be a risk that people will not read the sign – the sign may fall off or be removed or it will become invisible as people rush about in their daily lives.
So how can we solve these error traps in health and social care? We have created an error trap gallery for hub members to share examples of error traps they have come across and also examples of where action has been take and worked.
1. Steve Highley. An Encounter with an Error Trap. 6 August 2015. https://www.hastam.co.uk/an-encounter-with-an-error-trap/