Becker's Clinical Quality & Infection Control

19 Executive Briefing Sponsored by: How to reduce human error with resilient infection control O ver the last two decades, hospitals have been increasingly focused on reducing avoidable infections. This added emphasis on patient safety emerged in November 1999 when the Institute of Medicine published its landmark report To Err is Human: Building a Safer Health System. This study suggested that patients are less likely to be harmed by accidental injuries if systems of care include processes designed to prevent, recognize and quickly recover from errors. Provider focus on patient safety intensified once again after CMS imposed financial penalties on hospitals with high infection rates and provided incentives to those with low rates. In response, hospitals implemented a wide range of interventions designed to reduce infections, ranging from protocols for sterile procedures to hand hygiene training and surveillance, environmental cleaning standards, new cleaners and testing and diagnosis requirements. Despite these initiatives, however, hospitals have yet to reach zero harm. Human error is inevitable When it comes to infection control, human error is hard to avoid. Bacteria, viruses and other infectious agents aren't visible to the naked eye, so often there are no visual cues that prompt employees to employ best practices. When healthcare professionals engage in safe practices, it's often based solely on their own knowledge and memory. In busy hospital work environments, infection control simply may not be top of mind for employees already suffering from cognitive overload. Another contributor to human error is the fact that many healthcare workers see infection control as an added burden. In some cases, infection control protocols are perceived as so inconvenient that they inhibit patient care. Research published in BMJ Quality & Safety suggests negative mindsets are most common when infection control isn't viewed as an integral part of an employee's day-to-day responsibilities. 1 Additionally, employees often don't receive immediate positive feedback after adhering to infection control best practices. This lack of reinforcement can hinder a clinician's awareness of the influence their behavior has on patient outcomes. Ultimately, there is no product or intervention that can eliminate human error in healthcare, but providers can still pursue the goal of zero harm by planning and preparing for the occurrence of human error through behavioral science and organizational planning. Improving patient safety with human factors science Human factors science is a proven way to reduce human error in many different sectors, including infection prevention. 2 The goal is to make it easy for employees to access the information they need and to remember what actions must be taken to maximize patient safety. Examples of human factors science in action include using visual cues to prompt employees to engage in infection control best practices, placing supplies in easily accessible locations and providing rapid feedback about hospital infection rates. Designing environments that are resilient to human error With the knowledge that no product or intervention will be 100 percent effective, 100 percent of the time, it's important for providers to create an organizational structure that can account for the risk of error. A hospital may implement infection control interventions at multiple levels. For example: • At the organizational level, the hospital may enact surveillance programs to monitor compliance with infection control best practices. • At the technical level, the hospital may implement diagnostics and predictive software to proactively identify problem areas related to patient safety. • At the team level, employees may embrace a culture of infection control in which each person feels a sense of ownership for patient well-being. • At the individual level, workers may follow checklists to minimize infections and engage in regular handwashing. 1 Ward DJ. Attitudes towards infection prevention and control: an interview study with nursing students and nurse mentors. BMJ Qual Saf. 21:4;301-6. 2 Drews FA, Visnovsky LC, Mayer J. Human factors engineering contributions to infection prevention and control. Human Factors: e Journal of the Human Factors and Ergonomics Society. 61:5;696-701

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