Video Transcript: Error Reducing Principles

Doug Bonacum, CPPS; Vice President, Quality, Patient Safety, and Resource Stewardship, Kaiser Permanente

The list of error reduction principles you see here is not meant to be all inclusive. But it’s clearly a good start and they crosswalk nicely to the Hierarchy of Controls that we just looked at. Let’s go through all eleven.

One is simplification. This is simplifying the structure of tasks to help minimize the load on global cognitive processes like working memory, and to reduce waste. Two is standardization. This is about creating standard work, equipment, and materials, to better assess and improve outcomes. Orient and train new staff, and improve ease of use.

Standardization also requires us to clarify roles and responsibilities regarding both routine and infrequent tasks so that everyone is absolutely clear about who is accountable for what and how where and when we expect those accountabilities to occur. If it’s good for nuclear power plants, commercial aviation, and other high reliability organizations, it should be good for us as well.

Three is avoiding reliance on memory to minimize the risk of slips and lapses that we spoke about earlier in this module.

Four is improving access to information and intelligent decision support to improve efficiencies, reduce reliance on memory, and minimize mistakes by improving decision making.

Five is taking advantage of habits and patterns to make it easy to do the right thing, and to minimize the risk associated with shortcuts, workarounds, and drift from safe practice that all humans take.

Six is exploiting the power of constraints forcing functions to make it harder to do the wrong thing.

Seven is using visual controls to shape desired behavior.

Eight is promoting effective team functioning through enhanced strategies like simulation and development of communication skills to better leverage existing resources, minimize error, and recover from harm. High-performing teams also hold each other accountable and are more capable in confronting each other’s violations and drift in safe practice in the interest of patient safety.

Nine is employing redundancies where appropriate to capture and mitigate an error before it has a chance to do significant harm.

Ten is eliminating environmental factors that degrade performance such as clutter, inadequate lighting, excessive noise, and needless interruption and distraction. And finally, eleven, creating systems that are better able to tolerate the occurrence of errors and contain their damaging effects when they do occur. This includes actions and outcomes of practitioners, making them more visible through strategies like redundancies and substitution, and other mitigation strategies to minimize the impact of error.

All of these are present every day in our lives outside of health care and the trick is to really identify those and to think about how we might be able to apply them within our own settings.