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“We cannot change the human condition, but we can change the conditions under which humans work.” James Reason (2000)
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Healthcare professionals are among the most highly trained, driven, and conscientious professionals. Despite their commitment to delivering the best care possible, they can be set up for errors by poorly designed medical devices, uncoordinated care processes, and fragmented systems. Too often, these systems are designed in a way that does not account for how people actually interact with their work environment.
Human beings have limited attention spans and perform worse when they are fatigued. We cannot multitask, and we are forgetful. When we are required to go beyond these capabilities, errors can occur. In fact, research shows that human errors are responsible for 80-90% of errors. Urging clinicians to "try harder" or "be more careful" will not prevent these errors. To reduce or prevent such harms, the healthcare environment must be designed with human limitations and abilities in mind.
Experts classify human errors into three categories:
Cognition plays a factor in how we process the information available to us. We acquire information from the world around us, interpret and make sense of it, and then respond to it. Errors can occur throughout this process.
Because humans are not machines, we are unreliable and unpredictable, and our ability to process information is limited by the capacity of our working memory. However, we are also very creative, imaginative, and flexible in our thinking. This is useful when something unexpected happens and we need to adapt to the changing needs of the patient.
Humans can be distracted, which can be a strength and a weakness. This quality helps us notice when something uncommon is happening. We excel at identifying and responding to situations quickly and adapting to new situations and information. However, our ability to be distracted inclines us to error because we may miss key aspects of a task or situation. For instance, a nurse is in the midst of receiving a telephone medication order when a colleague interrupts with a question. She inadvertently writes the wrong dosage on the order.
Our brain has the ability to cause us to misperceive a situation thereby contributing to an error. Despite our best intentions, the fact that we can misperceive a situation is one of the key reasons that our decisions or actions can be flawed, resulting in making "stupid" mistakes despite experience level, intelligence, motivation, or diligence. In the healthcare setting, these errors can lead to patient harm.
The following table lists some factors that are likely to trigger error. (Seshia et al., 2018).
| Examples of error-catalyzing factors across the continuum of care |
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Organization- or team-related factors
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Individual-related factors (some are secondary to upstream organizational factors)
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Patient-related factors
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| Typically, several factors co-occur. These factors create holes in the "Swiss cheese" and may cause holes to align in several successive layers of defense. We refer to these phenomena as "breaching of the cognitive-affective gates" (discussed in the text). Authors' compilation from several references cited in the text. The list is not meant to be all-inclusive. |
These human factors often occur simultaneously and are all common in healthcare. Decisions can be influenced by a myriad of emotions created by workplace cultures, the nature of the task, and internal or external psychological factors affecting healthcare providers. Chronic high-stress situations, exposure to adverse influences, and excessive work hours can compromise decision making and lead to burnout. Patient-related factors are also important. The contribution of psychological factors to safety often goes unnoticed. Measures to mitigate the effects of the factors can improve patient safety.
“Human factors are a human-centered science using tools and methods to enhance the understanding around human behavior, cognition, and physical capabilities and limitations, and applying this knowledge to designing systems in support of these capabilities,” according to Erin Lawler, human factors engineer at The Joint Commission. (The Joint Commission (2015). Human Factors in Patient Safety Systems Analysis. The Source, Vol 13, Issue 4). Human factors science attempts to understand how humans perform under different circumstances. It aims to help people do their best work, improve resilience and overall system performance, and minimize errors. Human factors-based solutions make it "easy to do the right thing right the first time." When errors do occur, they are less likely to end in harm.
Human factors, therefore, examine the relationship between humans and the systems within which they interact by focusing on improving efficiency, creativity, productivity, and job satisfaction, with the goal of minimizing errors. A failure to apply the principles of human factors is a key aspect of most adverse events. All healthcare workers need to understand human factors principles. These are important considerations to recognize because they are reminders that making errors is all but inevitable. Reason described "error" as the failure of a planned action to achieve its intended outcome or a deviation between what was actually done and what should have been done.
In its broadest sense, human factors incorporate human-machine and human-human interactions such as communication, teamwork, and organizational culture. Human Factor engineering seeks to identify and promote the best fit between people and the world they live and work in, especially regarding technology and physical design features in the work environment. You will find further elaboration of this concept in the Human Factors Engineering section to come.
Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM
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