Professional Documents
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Lessons from
Human Factors
Nolan2 describes three principles for
the design of safe care: 1) designing
the system to prevent errors, 2) making
errors visible so they can be intercepted,
and 3) developing mitigation strategies
to reduce the impact of errors. These
principles can be further expanded to a
list of ten strategies that can be applied
to the design of patient care processes
to reduce error.
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Standardization. Standardization
Color-matching. Color-matching
items that are used together can
eliminate the need for the
healthcare worker to remember
which items go together, and can
prevent him or her from mistakenly
using the wrong items together.
Color-matching is different than
color coding in that the user does
not have to remember what a
particular color means. With colormatching, the user need only match
the colors on items in order to avoid
error. One effective use of colormatching is in IV, TPN or drainage
tubing, so that nurses can easily
identify which tubes are which and
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No. of Steps
.05
.33
25
.72
50
.92
100
.99
4. Reduce handoffs.
The higher the number of people
involved in a task or process, the greater
the likelihood of error. This is largely
due to communication failures that
occur during handoffs. Thus, reducing
the number of handoffs can be an
effective way of reducing the probability
of error. One example of how this can
be achieved is by scheduling work so
that workers do not have to be relieved
for breaks at critical times. Another
strategy to reduce handoffs is crosstraining and expanded responsibilities,
so that work does not have to be
handed off from one task specialist
to another quite so often.
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9. Manage fatigue.
As shift workers, healthcare workers are
particularly vulnerable to fatigue. This
problem is made worse by workforce
shortages, mandatory overtime and
double shifts. The effects of fatigue on
performance are similar to those of
alcohol. After 17-19 hours of
wakefulness, a normal day for many
shift workers, response times are up to
50% slower and accuracy is significantly
worse than when a person is intoxicated
with a blood alcohol level of 0.05%.11
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Conclusion: