Studying human performance can result in the creation of safer systems and the reduction of conditions that lead to errors.
Institute of Medicine, 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.
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, 2014a).
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, 2014a).
Risky behaviors often emerge because of systems-based problems in healthcare organizations. Common at-risk behaviors include:
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, 2014a).
Risky behaviors can emerge because of systems-based problems within a healthcare organization, eg, 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 health 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:
Staffing is linked inseparably to patient safety. For several decades, healthcare researchers have reported an association between nurse staffing and the outcomes of hospital care. Nurses are experiencing higher workloads than ever before for several reasons: increased demand for nurses, inadequate supply of nurses, reduced staffing, increased overtime, and reduction in patient length of stay (Hughes & Blegen, 2008).
In addition, patients in hospitals today are sicker, requiring greater care. This in turn means there are fewer nurses available to mentor and monitor new nurses, which only exacerbates the problem (Kibbe, 2010).
Several reports show that a relationship exists between lower levels of nurse staffing and higher incidence of adverse patient outcomes. Nurses’ working conditions have been associated with medication errors, falls, spread of infection, and even increased deaths (Stone et al., 2004).
While nurse staffing levels have been associated with the spread of disease during outbreaks, increasing nurse-to-patient ratios alone is not adequate; more complex staffing issues appear to be at work. Many studies have found that the times of higher ratios of “pool staff” (nursing staff who were members of the hospital pool service or were agency nurses) to “regular staff” (nurses permanently assigned to the unit) were independently associated with healthcare-associated infections (Stone et al., 2004).
Results from a number of studies in the last decade in the United States and Canada showed that for every additional registered nurse (RN) full-time equivalent per patient day there was a relative risk reduction in hospital-related mortality of 9% in ICUs and 16% in surgical patients. Greater RN hours spent on direct patient care were associated with decreased risk of hospital-related death and shorter patient stays (AHRQ, 2013a).
The consequence of high nursing workload includes adverse effects on patient safety and decreased job satisfaction for nurses, which contributes to high turnover and an increased nursing shortage (Hughes & Blegen, 2008).
Studies have shown that failure to obtain adequate sleep is an important contributor to medical errors. In addition to jeopardizing patient safety, clinicians who fail to obtain adequate sleep are also risking their own health and safety. According to the National Center for Sleep Disorders Research, sleep loss is the leading cause of drowsy driving and sleep-related vehicle crashes. Drowsy drivers have slower reaction times, reduced vigilance, and information-processing deficits, which make it difficult to detect hazards and respond quickly and appropriately. Decreased sleep has also been linked to the increasing epidemic of obesity (Hughes & Blegen, 2008).
Individuals working night and rotating shifts rarely obtain optimal amounts of sleep. Night-shift workers have been shown to obtain 1 to 4 hours less sleep than the norm. Sleep loss is cumulative and by the end of the workweek the sleep loss may be significant enough to impair decision-making, initiative, integration of information, planning, and vigilance. A sleep-deprived individual may not recognize these effects until they are severe (Hughes & Blegen, 2008).
Studies have also shown that moderate levels of prolonged wakefulness can produce performance impairments equal to or greater than blood alcohol levels that are deemed unsafe for driving or operating heavy machinery. Despite reported nurse satisfaction with 12-hour shifts, recent studies have shown longer shifts and frequent overtime are associated with the difficulty of staying awake on duty, reduced sleep times, and nearly triple the risk of making an error (Hughes & Blegen, 2008).
The environment in which healthcare workers practice can also contribute to medical errors. Studies show that healthcare workers were:
Not only can working conditions increase the chances for errors, the design of items in that environment can as well. 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 to the item intended. A 2006 study detailed a situation where an epidural penicillin solution was given instead of an intravenous (IV) penicillin to a 16-year-old pregnant patient’s IV line, causing her immediate death. The IV and epidural bags had similar designs (AHRQ, 2013a).
The design of medical devices, even the drawers of medication carts, can affect medical errors—both negatively and positively. A redesigned drawer resulted in shorter medication retrieval time and fewer wasteful actions. The prototype drawer also received higher ratings for visibility, organization, and general usability (AHRQ, 2013a).