Article: Nurses learn how to care for patients – they should also learn how systems can fail them

[Sly Saint]

A nurse can know exactly how to give a medicine safely and still be more likely to make a mistake if they are repeatedly interrupted, given confusing information or forced to search several computer systems for the details they need.

For patients, the consequences can be serious. Research has linked problems during clinical handovers with risks to safe care, while interruptions during medication administration have been associated with errors.
When something goes wrong in healthcare, attention often falls on the person who made the mistake. But patient safety also depends on the conditions in which doctors, nurses and other healthcare professionals are working. Is important information easy to find? Does technology help them do their job or make it harder? Can they concentrate on a task without unnecessary interruptions?

Understanding how these conditions affect safety is the focus of Human Factors and Ergonomics, usually shortened to HFE. HFE examines how people interact with the systems, technology, tasks and environments around them. In healthcare, it can help identify features of working conditions that support safe care or make mistakes more likely.

...some nurses can enter clinical practice without having been taught a structured way to recognise when the system around them is making their job less safe.

Poorly designed electronic records offer one example. Research has found that they can increase nurses’ workload and encourage workarounds, where staff find alternative ways of completing a task when the official system does not fit well with clinical work.

Imagine that important medication information is difficult to find. An experienced nurse may know where to look or which colleague to ask. The immediate problem disappears, but the flaw in the system remains. A newly qualified or temporary member of staff may struggle to find the same information during a busy shift.

Teaching HFE during nursing degrees could help students recognise problems like these before they begin working independently. It could also change how they think about mistakes.


Professional accountability remains essential. But patient-safety research shows why asking only who made an error can give an incomplete picture of why it happened. If a nurse gives the wrong medication after being repeatedly interrupted, their actions need to be examined alongside the circumstances in which the error occurred.

MSN

I don't think adding another layer of risk assessment theory to their studies is the solution.

Adequate supervision and systems that are fit for purpose would seem a better place to start IMO.