Failed barriers cause human errors
Redirect your remedial efforts
By Patrice Spath, ART
Brown-Spath Associates
Forest Grove, OR
When an untoward patient care incident occurs, the first tendency is to blame the person directly involved in the event. A common reaction is to wonder how any professional could have been so careless or reckless. Our natural tendency is to place blame for lapses in behavior squarely on those directly involved with the work. As a consequence, we have traditionally directed most of our remedial efforts at the people in question. We sanction them, we exhort them, we retrain them, and we write additional procedures.
Unfortunately, such measures have limited value. One reason for this is that they run counter to an important principle of error management: Errors are consequences, not causes. Identifying human errors is merely the beginning of the search for the root causes of the incident, not the end. Another basic principle of error management is that the best people can sometimes make the worst mistakes. Being trained for the job - being skilled and experienced - reduces the absolute rate of errors, but it does not eliminate them entirely.
A human error that results in an undesirable outcome is the last step of what is usually a much longer sequence of contributing factors. The chain of events leading up to an accident encompasses the nature of the task itself, the quality of supplies and equipment, the quality of communication among the health care team, the conditions within the workplace, and the way the delivery system is organized and managed. Errors are the product of many interacting factors - personal, task-related, situational, and systemic. Several structured root-cause analysis tools are available to help us identify the true causes of human errors.
Examine faulty safeguards
Barrier analysis is an analytic tool that can be used during the systematic after-the-fact investigation of patient incidents and employee accidents to determine what may have caused a human error. Barrier analysis examines the adequacy of the safeguards in the system that should have prevented the undesirable occurrence. The person or team investigating the event evaluates the barriers already in place in the process and examines all potential factors that may have caused a breakdown in one or more barriers. From this investigation, the root causes of the incident may be identified.
Consider the following event:
A newly hired operating room scrub nurse, working evening shift, found a small nick in her glove at the termination of a procedure. Upon removing the glove, she found that some of the patient's blood had inadvertently seeped through the glove and onto her skin at a spot where she had an open sore. The patient was known to be HIV-positive.
When we learn about an event like the one described above, we are inclined to attribute the cause to some negative characteristic of the person involved, such as laziness, carelessness, or incompetence. But if you were to ask the person why they failed to notice the nick in the gloves before they were exposed to a contaminant, they would almost certainly tell you why the particular circumstances surrounding the incident forced them to act in that way. Their unsafe act was most likely caused by a failure in one or more of the safeguards in the system. Hospitals have many physical controls, administrative controls, and human action controls in place to prevent an event like that one from happening. When an unintended incident occurs, use barrier analysis to look at the existing safeguards and see why they failed.
Barrier analysis is a useful technique to use throughout a root-cause analysis. Before root causes are identified, the team can use a barrier analysis to identify the causal factors influencing the event. If the root causes of some causal factors can't be found, the investigating team can still use the barrier analysis results to identify more effective barriers that will reduce the likelihood of the event's recurrence. The investigation team can conduct a simple barrier analysis by asking and answering the following questions about the event:
· What physical, human action, and administrative controls are in place as barriers to prevent this undesirable event?
· Where in the sequence of events would these barriers prevent this event?
· Which barriers failed?
· Which barriers succeeded?
· What other physical, human action, and administrative controls might have prevented this event if they had been in place?
Identify and understand all existing barriers
To accurately answer these questions, the investigation team should have a good understanding of the facts surrounding the event in the logical sequence as they occurred. The team should include members who can identify all existing barriers and have knowledge of the function of each barrier. They may need to obtain the input of people not represented on the team to perform the barrier analysis.
In private industry, several very structured barrier analysis techniques have been designed to examine the safeguards built into high-risk processes. One technique involves identifying the unwanted or undesirable end event(s) that resulted from the undesirable occurrence. These end events may be described as a loss, adverse outcome, or injury.
For the blood exposure incident, the unwanted outcomes could be grouped into categories: bodily injury, financial, and regulatory. Next, the targets of these losses are selected. For the blood exposure incident, the target of the bodily injury is the newly hired scrub nurse, the target of the financial loss is the institution (because of potential lawsuit and loss of goodwill), and the target of the regulatory loss is the institution (because of potential loss of accreditation by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, or citation by the state health department or OSHA).
Next, for each of the losses the team lists the barriers or safeguards currently in place to prevent the undesirable event. The list should include both barriers that were in place and those that should have been in place. The team is likely to find more than one barrier may be associated with each unwanted event. When listing the barriers, the team should describe the barrier's purpose and its intended function in eliminating hazardous conditions. They then should discuss the reasons why the current barrier didn't prevent the accident. When evaluating the effectiveness of barriers and controls, the team should have a good understanding of the function, location, and features of each safeguard. Obvious barriers are easiest to identify, such as latex gloves on the scrub nurse's hands. A barrier like new employee orientation to ensure compliance with universal precautions is less obvious. The investigation team may need to validate their results with those involved in the day-to-day processes to be sure all failed or unused barriers have been identified.
Once the team has identified all the failed barriers, they then evaluate the cause of each failure. Validation may need to occur at this step to ensure the team's assumptions are accurate. From these discussions, the team selects the root causes and begins implementation of an improvement plan. The results of the barrier analysis can also be used during the action planning phase, as it will likely reveal what barriers should have or could have prevented the undesirable event.
A barrier analysis worksheet is a useful tool in conducting a barrier analysis. (See worksheet that was completed using data from the case study, p. 137.) Its format is particularly useful for illustrating the results of the analysis in a clear and concise form. The chart also is an effective summary that can be used in the final report of the accident investigation.
While the barrier analysis technique helps identify multiple failures, they may not be the only root causes of the event. Other root causes could include system deficiencies, management failures, inadequate competencies, performance errors, omissions, nonadherence to procedures, and inadequate organizational communication. However, the results of barrier analysis can give the team a different perspective on the incident. It will help the team discover root causes that otherwise would have been overlooked if the team had only used less structured tools such as cause-and-effect diagrams.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content