What did you just do, page 3
IA is part of the human condition so it can never be completely prevented; the focus should be on reducing the chances of it happening by addressing the triggers above, with appropriate protocol and systems checking procedures.
Double-checking protocols
In clinical settings, verbal-response checklists are used frequently by health professionals to monitor their actions. Toft says that responses to verbal checklists are similar to a priest calling out and the congregation giving back the answers, except that in a church the congregation do not have to perform any actions unlike a health professional.
“You assume two things when you work closely with people: you assume your colleague has checked it; and you assume they have been as rigorous as you have. This happens automatically because colleagues trust each other,” explains Toft. “The mere fact that everyone agrees that there is no mistake is confirmation that there is no mistake even if there is. This is ambiguous accountability when a check is taking place.”
A system of verbal double-checking designed to prevent involuntary automaticity would be:
- examine the patient
- determine the problem
- determine what treatment is needed
- make a prescription
- print and give it to the patient
- ask the patient to read back the prescription to you
“I was chatting to a GP about IA and he said when he printed scripts for patients he generally never checked them, as he assumed that the prescription on the screen was for the person sitting in front of him,” he adds.
In a hospital, it is not always possible to double-check verbally treatment with patients. An electronic protocol was introduced by a team from the John Radcliffe Hospital, Oxford, led by Professor Mike Murphy, to cut down the risk of human error and IA in transfusion. They developed an “end-to-end” electronic blood tracking and transfusion management system, which demonstrated that one nurse with a handheld computer could reduce the incidence of errors.
Use of the “closed loop” transfusion system provides audio and visual warnings when the clinician is not following the correct protocol. Not only has the automated system cut down errors, but staff prefer it. Staff commented that it makes them think about what they are doing, and that it enables them to adhere to the protocol even when they are distracted or interrupted.