Studying human performance can result in the creation of safer systems and the reduction of conditions that lead to errors.
Institute of Medicine [sic], 1999
To Err Is Human: Building a Safer Health System
There are many systemic factors that increase the likelihood of a medical error. Some of the most important factors are risky behaviors by healthcare workers, staffing issues, sleep deprivation, and environmental factors.
Risky Behaviors by Healthcare Workers
At-risk behaviors are actions by healthcare providers that compromise patient safety. Healthcare personnel may engage in risky behaviors because the rewards are immediate and the risk of patient harm seems remote. They may engage in risky behaviors when they become comfortable and competent with a task and lose the perception of risk. These behaviors often result in convenience, comfort, and saved time (NCCMERP, 2014).
The perceived benefits of taking a risky shortcut leads to repeated at-risk behaviors, despite the healthcare provider’s possible knowledge, on some level, that patient safety could be at risk. In addition, as one healthcare worker has apparent success with an at-risk behavior, they will likely influence fellow workers until that behavior becomes a standard practice (NCCMERP, 2014).
Risky behaviors often emerge because of system-based problems in healthcare organizations. Common at-risk behaviors include:
- Engaging in “grab and go” with a medication without fully reading the label before it is dispensed, administered or restocked
- Intimidation or reluctance to ask for help or clarification
- Failure to educate patients
- Using medications without complete knowledge of the medication
- Failure to double check high-alert medications before dispensing or administering
- Not communicating important information such as patient allergies, diagnosis/co-morbid conditions, weight, and so on (NCCMERP, 2014)
When patient harm occurs, an organization often focuses on the “sharp end” of the medication-use process—the front-line healthcare workers involved in the event or engaged in the at-risk behavior. However, punishment based only on the outcome when other instances of at-risk behavior by an individual or group go unnoticed is often ineffective and can send the wrong signal to staff (NCCMERP, 2014).
Risky behaviors can emerge because of system-based problems within a healthcare organization, for example, an organizational culture with a high tolerance of such behaviors. Healthcare managers should review organizational behaviors regularly. Unnecessary complexity in processes provides many opportunities for workers to take risks when providing care to a patient.
The National Coordinating Council on Medication Error Reporting and Prevention (NCCMERP) makes the following recommendations to reduce medication errors associated with at-risk behaviors:
- Eliminate organizational tolerance of risk.
- Increase awareness of at-risk behaviors.
- Determine system-based reasons for risk-taking behavior.
- Eliminate system-wide incentives for at-risk behaviors.
- Motivate through feedback and rewards.
- Involve patients and families in the processes of safe medication administration and monitoring (NCCMERP, 2014)
Understaffing, Sleep Deprivation, and Environmental Factors
The risky behaviors discussed above as they relate to patient safety are especially focused on their contribution to medication errors but in some cases those behaviors and other factors contribute to other errors. While studies have been done that look single factors, such as understaffing or sleep deprivation or environmental factors as they affect patient safety, these may also be seen as a complex of factors that can feed off of each other.
Understaffing and Sleep Deprivation
Recent research has found that understaffing is directly related to a higher risk of adverse events for patients, including medication errors. It has also been argued that, while hospitals tend to blame understaffing on a nursing shortage, research has shown that “We have more nurses in the United States than we’ve ever had before” and the real problem is a failure to budget effectively for the nursing staff required for patient load (Jacobson, 2015).
A research study on hospitals worldwide showed that higher nurse-to-patient ratios correlate with lower patient deaths in intensive care units, while another study showed that an increase of one patient in a nurse’s workload increased the risk of death of one patient in that hospital was 7% (Jacobson, 2015).
Minimum staffing ratio laws have been proposed in some states but encounter stiff resistance. However, California did pass such a law in 2004 and has seen improvement in patient adverse events. In one study of hospitals across the United States it was found that hospitals with higher staffing ratios had a 25% lower likelihood of being penalized under ACA rules for excessive readmissions when compared with those with lower staffing ratios. A related study found that each additional patient per nurse raised readmission rates 6% to 9% (Jacobson, 2015). An interesting side benefit is that occupational injuries for nurses also decline when nurse-to-patient ratios increase.
Sleep deprivation is another factor affecting healthcare professionals and, while it is an issue on its own—many things can contribute to one becoming sleep deprived—it can also be related to staffing issues if workers are asked or required to work overtime or additional shifts and simply are unable to obtain enough sleep. Sleep deprivation has been shown to affect executive-level function and mood and also increase irritability, which can negatively affect team functioning in healthcare settings and lead to burnout. The Joint Commission has issued several reports regarding the potential for adverse effects of sleep deprivation (AHRQ, 2019b).
A 2013 Kronos Inc. survey of nurses found that two-thirds had nearly made a mistake at work due to fatigue while 25% said they had made a fatigue-related error. Additional findings included significant numbers of nurses reporting inadequate or unsatisfactory staffing levels, fatigue both at the beginning and end of shifts, facility disregard of rest periods, and facility failure to manage extended shift issues and scheduling problems (Bird, 2013).
The environment in which healthcare workers practice can also contribute to medical errors. Studies show that healthcare workers were:
- Almost 3 times more likely to report a more hectic working environment in the 30 minutes before the error compared to the rest of the error shift
- Nearly 2 times as likely to report a more hectic working environment when comparing the error shift to the prior shift
- Four times more likely to report a more hectic working environment when comparing the 30 minutes before the error to the prior shift worked (Grayson et al., 2005)
Not only can working conditions increase the chances for errors, but the design of items in that environment can also. For instance, AHRQ cited a study examining the design of the computerized physician order enter (CPOE) interface that required about 10 clicks per order, thus significantly increasing time needed to enter orders. The poor usability of the CPOE system and its lack of integration with clinician workflow contributed to delays in patient care that were a major factor in the increased mortality rate after CPOE implementation (AHRQ, 2013a).
Medication and product packaging can look similar and result in errors choosing the correct item. The design of medical devices, even the drawers of medication carts, can affect medical errors—both negatively and positively. In one instance a redesigned drawer resulted in shorter medication retrieval time and fewer wasteful actions (AHRQ, 2013a).