In Focus
Considering the Human Factor in Error Management
‘To err is human’ but why do people make mistakes?
Errors and non-conformances can arise anywhere in the transfusion chain. They may apply to products, services, processes, equipment, goods from suppliers, or the quality management system itself. The possible causes could be technical, electrical, system failure, computer error, insufficient resources, acts of nature such as fire, floods, earthquakes, or human factors. The focus here is on considering the human factors.
Human factors leading to errors
We know ‘to err is human’ but why do people make mistakes? Possible factors could include a lack of skills, inadequate training, or bad planning, either by the person or by management. Issues that are more difficult to deal with are negligence, incompetence, or a negative attitude. Stress also plays a large role in daily life and may lead to errors. Stress could include work pressure, time constraints, health issues, family problems or financial concerns.
Consider how you personally feel when you make a mistake. What is your reaction? Everybody is likely to react differently. When an error occurs, consideration should be given to how individual staff feel. This needs to be dealt with sensitively as there will be a range of responses. One common reaction is embarrassment or disappointment as nobody likes to make mistakes. There may be frustration or anger, either with oneself or with others, or perhaps with the system. Other possibilities are defensiveness or denial and a fear of consequences. Each type of reaction needs to be handled differently.
Norman, in his book titled The Design of Everyday Things1, stated that “People make errors, which lead to accidents. Accidents may lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.”
Investigation of errors and their causes
Errors should be investigated in an honest and open way and be seen as opportunities for improvement. Corporate culture plays a role in error management. If the establishment's practice is to encourage event reporting with a consistent response that everybody learns from inadvertent human errors, then the culture becomes safer for staff to report minor events that if followed up and corrected, may prevent major events. Acknowledgment to staff that events were reported, and the systemic error corrected, also signals that the first approach to errors or accidents is evaluation of quality management systems and not blaming, shaming or punitive action. This builds trust in the system and confidence in overall quality of products and services. The use of root cause analysis provides a structured approach to investigation which will identify opportunities for improving systems and processes. It will also identify where additional training, or re-training, is required. It is beneficial to solicit input from staff on possible process modifications and improvements as they are the ones most familiar with their tasks.
The following tips may be useful in error management: • Look at management practices, policies and procedures before looking at staff • Do not play the blame game • Face problems, don’t ignore them • Use available tools to tackle the problem; be creative • Ask for help; involve other staff or work areas • Don’t procrastinate! Get the monkey off your back as quickly as possible.
Where staff willingly accept responsibility for their mistakes, they need to be supported in dealing with the consequences of their actions and in finding appropriate corrective actions. However, the principle of accountability must still apply. Repeated errors by the same individual will need serious discussion and appropriate measures will need to be taken. (Table 1)
Table 1. Root causes
Where punitive action is required, it is best to follow a fair and clearly-defined disciplinary policy. Organisations should develop their own procedures but the approach of an initial verbal warning followed by written warning(s) may be followed. If the issue is not resolved a disciplinary hearing may be warranted which may result in dismissal in a worst-case scenario. Due to the nature of blood transfusion tasks, errors may have serious consequences for donors or patients. If legal action does arise, it is best to obtain the advice of lawyers to minimize damage, both reputational and financial.
Management commitment
The attitude with which errors and incidents are managed is often a reflection of the level of commitment and support that management provides to quality systems in the blood establishment. It is also important to celebrate the positives with staff such as a reduction in the number of non-conformances, errors and incidents over time and continuous improvement achievements. Within an establishment there will be individuals who excel at looking for solutions and these problem-solving champions should be recognised.
In closing, it is worth remembering these two quotes:
“When you make a mistake, there are only 3 things you should ever do about it: admit it, learn from it, and don’t repeat it.”
Paul Bear Bryant
“It’s not how we make mistakes, but how we correct them, that defines us.”
Rachel Wolchin
References
- Norman D. The design of everyday things. New York: Basic Books; 1988.
- WHO Guidance on Implementation of a Quality System in Blood Establishments.
