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Internal Medicine

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Human Factors and Safety

No matter who you are, how smart you are, or how hard you try, you can always make an error. How many of us have walked out the front door only to realize we left our keys on the counter?

 

Human beings by their very nature are hardwired in such a way that errors are inevitable, and given certain circumstances - such as being tired, bored, distracted, stressed, or frequently interrupted - the chance of making errors goes up exponentially. 

 

The purpose of my post is to build awareness of the ways in which multiple factors in the workplace, involving both people and their surroundings, can contribute to error.

 

The following case study is based on a true story

 

Karen, a pediatric nurse with seven years of experience, is working her final shift of the week. It's been a particularly hectic day because three staff nurses are out on leave, and the nurses filling in are not familiar with the unit. 

Karen checks the electrodes taped to the chest of a four-year-old patient. She is about to reconnect the lead cord that will attach the little girl to the heart monitor machine at the bedside, when she learns she has an urgent phone call from her daughter, who is sick.

After speaking to her daughter, Karen rushes back to her patient. She is once again about to reconnect the patient to the heart monitor. At that moment, Joan, a new nurse, sticks her head in the doorway to ask about fixing a broken bed.

Karen stops what she is doing to patiently help Joan, explaining whom to call and what form to use. Finally, she tries to connect the two power cords she is holding.

Unfortunately, Karen does not realize one of the cords is actually not for the heart machine— it is, in fact, the lead to a new portable IV pump, also nearby. At first, she cannot make the cords fit together. But with a little extra force, they connect. The moment they do, a lethal current of electricity streams through the patient's body. The little girl dies instantly.

 

In the tragic story you just read, Karen was set up for failure. What factors contributed to her error? More importantly, how should it have been prevented?

Mazen Kherallah
D B T
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