Hearing “Paging Dr. Strong” on the intercom system does not necessarily mean the operator is summoning an actual Dr. Strong. Some facilities use that code to call in the security guards to deal with misbehaving patients or visitors. Code Silver in one hospital may refer to “missing person” and in another “somebody with a gun.” These codes might be standardized across a hospital or a hospital system, but there is little standardization across regions or states.
Rules for abbreviation use generally focus on medication safety—identifying visual and textual ambiguities that may confuse other medical professionals. The ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations includes items like IU that could appear like IV or 10; and DPT, which could stand for Demerol-Phenergan-Thorazine or diphtheria-pertussis-tetanus.
One barrier to change is resistance by those who have not experienced a bad event. Most of us were trained to learn from our personal experience; quite useful in many situations, especially when scientific evidence is weak or absent. Given the vast variety of situations patients present with and the limits of scientific evidence, there are many situations in which human intuition and experience are valuable. You can often hear experienced professionals say that they made a “gut” decision; one made from instinct and intuition developed through their own experiences.
A frequent response to an adverse event is to retrain the staff. However, training is often criticized as a very weak and inappropriate response to problems, unlikely to result in significant sustained improvement. That criticism is correct, to a point.
A recent paper discusses the difference between appropriate and inappropriate training from the human factors standpoint . Training as the sole or primary intervention may be of marginal value as system design issues are often part of the problem.
Henriksen K, Dayton E, Keyes MA, et alPatient Safety and Quality: An Evidence-Based Handbook for Nurses (Chapter 5). AHRQ Publication No. 08-0043, April 2008.
This Agency for Healthcare Research and Quality (AHRQ) handbook examines the broad range of issues involved in providing high quality and safe care in all health care settings. This section of the guidebook provides a framework for collaboration between health care and human factors, and addresses the interdependent system factors that underlie patient safety.
National Health Service Patient Safety First Campaign
This guide provides an introduction to the concept of human factors in
health care and provides suggestions of how its elements can be applied by individuals and teams working to improve patient safety. It aims to build awareness of the importance of human factors in making changes to improve patient safety.
World Health Organization (WHO) Patient Safety has identified human factors measurement tools falling into four categories: organizational/managerial, team, individual, and work environment. The tools within each category fall into numerous categories, including communication, decision-making, and situation awareness.
James ReasonDepartment of Psychology, University of Manchester
The basic premise in the system approach is that 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 … Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work … When an adverse event occurs, the important issue is not who blundered, but how and why the defenses failed.