Some fundamental tenets to remember as we talk about developing systems to make healthcare “mistake proof”:
- Everyone commits errors.
This is the basic premise from which error-proofing evolves. Human beings are by nature imperfect. While this seems to be common sense, too often it is the thought that was missing in systems design that allows for a major error. Designers often do not think of the common user. What may seem obvious to an expert may be counterintuitive to the novice user. What may be simple in the design lab may be difficult in the real work environment.
- Healthcare professionals don’t come to work intending to harm a patient.
Healthcare workers are intelligent, caring people who are employed in a highly complex field. Systems need to be developed in that light, to make it easier for people to do their jobs without error.
- Complex systems fail.
The more complex a system is, the greater the likelihood it will fail. Simplifying and creating redundancies will reduce error. Awareness of potential failure points and ongoing focus on reducing, removing, and reinforcing possible points of error are essential.
For more detail on these issues, see Module: Anatomy of an Error.