You’re getting into your brand-new car to drive to work. When you try to put it in reverse to back out of your driveway, you notice you have to step on the brake first. You forget to buckle your seatbelt—and a chime activates as a reminder. When your car reaches a certain speed, your doors lock automatically. Once you get to work and park your car, you leave your keys in the ignition, and another chime reminds you to take them with you. The headlights turn off automatically.

The automobile industry has implemented these features based on an understanding of how human beings interact with their vehicles. It’s an example of human-factors engineering—the scientific discipline concerned with understanding the interactions among humans and other elements of a system. Human-factors engineering applies theoretical principles, data, and methods to design in an effort to optimize human well-being and overall system performance.

Human-factors engineering (also known as ergonomics) has three domains:

• physical (workplace layout)
• cognitive (mental processes)
• organizational (communication and teamwork).

Increasingly, elements of human-factors engineering are being used to improve the safety of nursing practice. To understand how the healthcare environment can be modified optimally through this lens, we need to understand the vulnerabilities and strengths of human performance.

Threats to safe nursing practice

Many workplace conditions can reduce the nurse’s performance:

• unfamiliarity with the task at hand
• inadequate time
• poor communication
• underestimation of risk
• poorly designed workflow.

Noted psychologist James Reason found the likelihood of error approached 75% when a person performed a new procedure without being aware of the potential for adverse events. Compare this to a 0.05% error rate when a skilled person who understands potential risks performs the same task. An example of leveraging human-factors knowledge is limiting the insertion of peripherally inserted central catheter (PICC) lines to a small team of specially trained nurses whose workflow is designed to minimize competing priorities. (See Using human-factors knowledge to improve unit safety by clicking the PDF icon above.)

We also have increasing evidence that the following factors promote human error:

• lack of sleep
• fatigue
• illness
• boredom
• fear
• stress
• reliance on memory
• interruptions and distractions
• noise
• inadequate lighting.

Studies examining nurse fatigue have found that nurses who work shifts of 12.5 hours or longer are three times more likely to make errors. Additional studies suggest sleep deprivation can have the same dangerous effects as a blood alcohol level of 0.05%. We would never knowingly let an intoxicated nurse care for patients—yet we routinely allow sleep-deprived nurses, who have the same degree of impairment, to do so.

In 2011, The Joint Commission issued a sentinel event alert on healthcare worker fatigue, advocating that hospitals redesign work schedules to reduce the amount of dangerous extended-shift work. It also encouraged hospitals to develop teamwork plans to support fatigued staff in efforts to improve patient safety. Furthermore, we need to consider the impact of fatigue as we examine the causes of adverse events. (See Factors in drug-administration errors.)

Using checklists

In light of our abundant distractions, it’s not surprising nurses are prone to errors of omission. Checklists have emerged as valuable tools in reducing omissions. One study found simple checklists for central line-insertion and daily goals directed at preventing infection significantly reduced central-line bloodstream infections in a critical care unit.

Some people criticize checklists as “cookbook medicine” and suspect they suppress critical thinking. This raises the question: Are all human factors essentially negative traits that need to be managed? Certainly, this isn’t true; the trait of advanced, adaptable cognition displayed by those working in complex environments provides resilience to the system. The uniquely human contributions of creativity, judgment, and situational prob¬lem solving are inherently positive and can’t be automated. Memory aids, such as checklists, promote higher-level cognition by freeing the mind of the burden of storing these task lists in its working memory.

Applying human-factors knowledge to error prevention

Acknowledging and examining the role of human factors in errors yields valuable insight into how errors can be prevented. Before an effective action plan can be developed, the true root cause of an event must be identified. Human factors also should be considered when evaluating the likelihood that an intervention can prevent a particular event from recurring. Clearly, some interventions are more efficacious than others.

The National Center for Patient Safety has created a hierarchy of interventions to help inform and improve the quality of action plans. This hierarchy has three tiers—stronger, intermediate, and weaker.

• The stronger tier consists of interventions that eliminate the chance of an error. Engineering controls known as forcing functions (such as the need to step on the brake to put your car in reverse) are a prime example. In health care, an example is tubing specifically designed to prevent the nurse from connecting enteral tubing to I.V. tubing. This control can help safeguard even those patients being cared for by sleep-deprived nurses working in suboptimal environments.
• The intermediate tier involves strategies to make it easier to do the right thing and to make errors visible. For example, placing hand foam outside every patient room promotes compliance with hand hygiene.
• The weaker tier involves mitigating error consequences by providing education and training. Your car mitigates the consequences of a collision by deploying an air bag. Placing a patient in a low bed limits the severity of injury from a fall. Education and training as stand-alone interventions are notoriously ineffective in preventing errors. Imagine you hit a vehicle in your mirror’s blind spot as you back up. In response, would you review your car’s instruction manual to prevent a similar accident? Can knowledge somehow make objects appear in a blind spot? A more efficacious strategy would be to choose a car with a rearview camera and parking sensors.

Understanding how nurses interact with the environment enables us to engineer processes that maximize nursing performance and dramatically improve patient safety. With diligence, our time at work can become as smartly and safely engineered as a commute to work in a car with the latest smart technologies.

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Susan Tocco is the director of Patient Safety and Transformation at Orlando Health in Orlando, Florida.