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  • Error traps: Let’s raise awareness

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    • Health and care staff, Patient safety leads

    Summary

    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.[1] 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.

    Content

    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.

    View our error trap gallery and share your examples

    Reference

    1. Steve Highley. An Encounter with an Error Trap. 6 August 2015. https://www.hastam.co.uk/an-encounter-with-an-error-trap/

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    I have no healthcare experience but would like to respond from an Industrial H&S and QMS background.

    While your medicines all look the same, their barcode differentiates.

    Scanning the barcode into the patient's care plan enables the  software checklist to detect the error. Having detected the medicine error and volume the computer alarms in front of healthcare worker and patient. Impossible to ignore the error is corrected. Error is reduced by a factor of 10,000.

    More information at posting " Ward-patient eQMS with error recovery protocols..."

    Kind Regards

    Derek Malyon.

     

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    Hi Swoo

    Thank you for the downloads implying the patient is protected from incorrect medicine and volume as displayed in the gallery. Is my assumption correct.

    Thank you for your post.

    Kind Regards

    Derek.

     

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    Hi Swoo.

    I only received downloads. No comments received. Did you want to provide a typical ward issue and solve it with an eQMS?

    If so, I present ward case file 3. paraphrased from 540-170 words from this download. 

    .Human-Factors-How-to-Guide-v1.2 (14).pdf

    A nurse was in charge of the night shift with an agency nurse on duty with her. A heparin infusion needed replacing. The nurse partly drew up the infusion but was distracted coming back latter to find it missing and told by agency nurse it was administered to the patient. The dose was corrected and no harm came to the patient.

    When the Ward Sister arrived, the nurse discussed what had happened. The following day the nurse received a call at home to say the senior nurse wanted to take the matter further, there would be an investigation and she was suspended from drug administration until a formal disciplinary hearing had taken place.

    At the hearing she was reprimanded for failing to follow protocol by not immediately completing an incident form and failing to better supervise the colleague who had administered the drug. She was given an oral warning to be kept on record for six months and required to be reassessed on drug administration. Five weeks later, the nurse resigned.

    eQMS solution.

    (1) Use barcoded manufactured drugs sized for the job.

    (2) Nurse and patient log-on with their wrist data. Medicine barcode scanned.

    That's about it. The computer software checklist does the hard work. If any error occurs the hooter alarms, nurse corrects error in-front of patient.

    Please get back to me if other ward issues are getting difficult to prevent.

    Thank you for your question.

    Derek.

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