Monday, April 27, 2009

STLs happen

Acting on an urge to find an outdoor spot to enjoy a warm spring evening, my husband and I recently found ourselves perched on a deck three stories above an old tavern, giving us a bird's eye view of the old courthouse in the small southern city where Larry Flynt, the publisher of Hustler magazine, was gunned down in 1978. I didn't know this fact, although I've lived in nearby communities for over two decades, but my husband did. This Trivial Pursuit-worthy fact, coupled with an old red pick-up truck that was missing the entire driver's side door (but, happily, not the driver) occupied our conversation until I remembered we were right down the street from the new courthouse (where I had been a jury member when a fellow citizen sued the Troy-Bilt company following a chipper-shredder mishap in the mid-1990's). We were destined for good conversation.
  • Targeting, then deliberately shooting, a fellow citizen with a handgun
  • Driving a motor vehicle absent a key piece of personal protective equipment
  • Getting your hand stuck in the business end of lawn and garden equipment
These are three very distinct ways to screw up. (Normally, I'd use the term err--as in To Err is Human--but, hey, it was Friday night.) My husband, of course, would have preferred to continue talking about Larry Flynt, Hustler, or the guy in the truck without the door. But I was determined to talk human factors engineering, the study of how people, given our capabilities and limitations, can be predicted to perform tasks that involve using machines under real world conditions.

"Did you know," I asked, "that the probability of a well-trained, motivated, competent person producing an error while performing a routine task is 1 in 2000?"

Erring while doing something you know how to do is a mistake characterized as a slip, trip, or lapse (STL), and STLs are the most common of human errors. Bringing home Coke instead of Diet Coke or Fruit Punch Juicy Juice instead of Cherry Juicy Juice are classic STLs. Environmental factors, such as similiar packaging, product placement on the shelf, lighting in the grocery store, and distractions during the selection process play a role in STLs. Irrespective of intention, STLs happen, and they happen most often to seasoned people performing tasks and activities they are normally adept at doing. If it happens in the grocery store, it can happen at work.

The chipper-shredder mishap I heard during my jury service could be characterized as a slip, trip, or lapse. (The gentleman who brought the suit was raised on a farm and had used heavy equipment since the time he was a young child.) When an experienced, but busy or distracted, nurse attaches a syringe containing viscous liquid, meant for oral administration, to an IV line and inadvertently administers it intravenously, you've heard another account of a slip, trip, or lapse.

I still haven't gotten over the fact that I learned about slips, trips, and lapses while serving on a jury, instead of during the course of my professional training ten years earlier. How helpful it would have been to know that systems could be designed and engineered in order to compensate for mistakes competent professionals can be predicted to make. (At the risk of beginning a rant, let me point out that in the U.S., we landed a man on the moon three decades before oral syringes--devices that are incompatible with IV tubing and thus prevent competent people from having a 1-in-2000 slip that can kill a person they're trying to cure--became commercially available in hospitals.)

I write about medication safety over at Medscape, on a popular blog called On Your Meds. This forum draws tons of comments from front line clinicians. Most use it to talk about what's it like to use existing processes to deliver the meds (and the care) they want to give. A few weeks ago, On Your Meds received over 8,000 hits in the first 24 hours after a piece entitled, "Medication Misadventures" was posted.

If you're a front line clinician, I encourage you to check out the hundred or so comments in response to "Medication Misadventures," reflecting about the safety problems others perceive, how your system benchmarks with others, and how well you (and your patients) are protected from predictable slips, trips, and lapses.

If you coach, lead, or manage front line clinicians or have a role in funding the systems (equipment, software, and the support services needed to fully operationalize them), I encourage you to read the comments left in response to "Medication Misadventures." Comments are simply electronic footprints, showing clinicians' perceptions about the fitness of the medication use system. These are people (your people, perhaps) interacting with machines under real world conditions. How well is your medication use system engineered to account for human factors?

If you sell medication safety, remember to talk about human factors when you come calling. We're not shooting our fellow citizens with a hand gun. But we may be tempted to drive an old pick-up, and we regularly have to dislodge pieces of cat brier from the chipper-shredders we use to get the job done.

And if you design equipment or systems that will make the medication use system safer, please get back to work. We need you.
Off to mulch..... stay safe and come back soon!


bucket trucks said...
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