I am involved in risk management standards for clinical laboratories, where the focus has been on understanding how manufacturer’s devices can fail and how a clinical laboratory can put in place control measures to prevent these failures from causing harm.
My concern with these standards is that there is not enough emphasis given to the clinical laboratories own sources of error – its people. Among problems related to human errors are cognitive errors, non cognitive errors, reckless behavior, and at risk behavior – the topic of this entry.
At risk behavior is behavior that increases risk where risk is not recognized, or is mistakenly believed to be justified. Anyone who manages people must have had the experience by hearing (perhaps second hand) “I don’t think that’s necessary and I’m not going to do it.” And of course, parents are familiar with at risk behavior practiced by their children.
An example of healthcare at risk behavior is reusing syringes. This occurred recently at an endoscopy clinic in Nevada and has affected up to 40,000 people. In reading the patient empowerment blog, one learns about other cases of reused syringes. In a case in Long Island, the physician reused syringes only for the same patient, but the syringes were used with multi-dose vials and these vials were used across patients.
In the recent case of reducing central line infections, Dr. Peter Pronovost observed that of the steps associating with placing a central line, in a third of patients, doctors skipped at least one step. Whereas, some of this could be attributed to non cognitive errors (slips), it could also be associated with at risk behavior. The control measure that worked here, was a double check step, whereby another healthcare provider would check to make sure each step was followed.
Discovering at risk behavior may not be easy, hence it needs to be on one radar’s screen.