A Close Call
I found out I was allergic to morphine when I was four years old. My parents always stressed the importance of telling people around me about it in case I was injured and couldn’t advocate for myself. Recently, I had minor surgery that required a brief overnight stay in the hospital. All my physicians are in the same hospital network and my information is in the computer system. Even then, every person I interact with asks me about my allergies. On my surgery day, it was discussed again, a red bracelet with the word ALLERGY on it placed around my wrist. When I woke up from anesthesia, I learned someone had written orders for morphine. Fortunately, a nurse had flagged it and had a discussion with my family, who immediately sounded the alarm.
I am grateful for the nurse’s thoroughness and her confirmation before proceeding. She prevented what would have been a miserable evening for me. Despite all the technology, the multiple reviews of my records from anyone I encountered, and all the checks in place, a mistake was nearly made.
Reliance on Technology
Technology has become integral to the fabric of our daily operations. We rely on technological systems to prevent errors and help guide our decisions, which can lead to complacency. The Institute for Safe Medication Practices gives these surprising statistics, “Clinicians overrode their own correct decisions in favor of erroneous advice from technology between 6 to 11% of the time, and the risk of an incorrect decision increased by 26% if the technology output was in error.”
An important part of any relationship between companies and their customers is trust, particularly where physical, financial, and privacy concerns exist. A simple double check can mean the difference between a near miss and a negative event. Specific industries encounter higher risks due to the nature of their business, such as healthcare, financial services, technology, and manufacturing. Extra precautions should be in place to increase trust and protect reputations.
Addressing Human Error
Human error is common and should be factored into an organization’s risk framework. Even the most skilled individuals in a field can have a lapse or slip. Error prevention must be structured and proactive. Risk management frameworks should account for these elements. Though technology is an excellent tool, it should not serve as a replacement for workers’ attention. Training, decision-making aides, and procedural checklists are essential in reducing risk.
Consider the external and internal factors that may influence performance. Review job, personal, and workplace factors that could lead to risks. Build those considerations into your risk analysis. Encourage reporting of near misses and good catches and use them as a teaching tool. Be sure these procedures have an option for anonymity and do not assess blame. Transparency in your organization helps employees gain confidence to learn and engage. Don’t forget the human factor and its important role in daily business decisions.