Addressing human factors in decontamination

Ensuring that surgical processing departments are well-run is of great importance, as these departments are responsible for decontaminating reusable surgical equipment and for delivering it, as required, to operating theatres. Decontamination involves several  processes, occurring within dedicated facilities, including cleaning, disinfection and sterilisation, which ensures reusable surgical instruments are safe for further use on patients.

The operation requires maintaining a well-ordered facility, ensuring it is clean and decontamination practices can be consistently reproduced. While most units have well-written procedures, human errors will happen and these can sometimes lead, in the most serious cases, to the transference of contamination and patient infection (healthcare-associated infections). While human failure is normal and predictable, it can be identified and managed. Hence, errors can be reduced by reviewing how surgical processing departments are managed and how personnel operate, in particular, by reducing the level of variability. An approach that can deliver success in this area is the ‘human factors method’.

This article looks at three areas where human factors approaches can assist with improving performance through lowering variability and, hence, reducing contamination rates. These are: Development of procedures; Training; Space and ergonomics. Prior to this, the article introduces the subject of human factors and looks at sources of variability within surgical processing departments.

Sandle, T. (2023) Addressing human factors in decontamination, Clinical Services Journal, 22 (7): 39-43
 

To read, see: Human Factors

Posted by Dr. Tim Sandle, Pharmaceutical Microbiology Resources (http://www.pharmamicroresources.com/)

Managing workplace human error

 

Managing Workplace Error Part 1: Unpicking Patterns Of Human Error

 

It is well established that regulators do not like the root causes of deviations to conclude ‘human error’ and for the resultant corrective or preventative action (CAPA) to recommend additional training. Instead, regulators expect organizations to go deeper and to unpick the underlying reasons as to why a person made an error and, from this, error risk reduction actions can be initiated. Probing the cause of human error can be achieved through an interactive process, such as by asking ‘why’ multiple times until the answer emerges (this parallels the 5-whys technique or the repetitive questioning of a recalcitrant child).

 

The paper demonstrated why simply resorting to ‘human error’ as the root cause of an incident is often inaccurate and generally prejudicial; it also hides too much about how a system functions or malfunctions and hence prevents an appropriate preventative actions from being formulated. As an adjunct to this, this article looks more closely at why human error may occur.

 

Sandle, T. (2022) Managing Workplace Error Part 1: Unpicking Patterns Of Human Error, IVT Network, at: https://www.ivtnetwork.com/article/managing-workplace-error-part-1-unpicking-patterns-human-error

 

Managing Workplace Error #2: Getting to the Heart of the Matter Through Human Error Checklists

 

In terms of how human error can be defined, then one potentially useful definition of human errors is as “any member of a set of human actions that exceed some limit of acceptability, i.e., an out-of-tolerance action, where the limits of tolerable performance are defined by the system”. In other words, an outcome that was not intended or desired. At first glance the cause of a human error may seem straightforward, all too often followed by the hasty conclusion that training or retraining can fix the issue. However, ‘human error’ is very rarely the root cause and instead a more detailed and iterative human error root cause analysis investigation will more often reveals a deeper issue at the heart of the matter and allows for an appropriate preventative action to be set.

 

This article looks at a process of defining human error and provides some guidance on constructing a checklist for getting to the root of the error. In following this method, there are very few cases of actual human error; instead, there is typically a fault with a system, procedure, knowledge, or with the environment within which the error occurred.

 

Sandle, T. (2022) Managing Workplace Error #2: Getting to the Heart of the Matter Through Human Error Checklists, IVT Network, at: https://www.ivtnetwork.com/article/managing-workplace-error-2-getting-heart-matter-through-human-error-checklists

 

Managing Workplace Error #3: Dissecting Reasons and Causes of Laboratory Error

 

This article looks at some of the reasons for, and patterns behind, laboratory errors. The article represents a brief look into the subject area, drawing on some of the issues that the author is aware of. Generally, laboratory errors should not be categorized as "human error" since these are not the problem but generally a symptom of a system or facility or operation. By delving deeper into the nature of the event (using techniques to get to the real cause of the problem) more meaningful CAPAs can be developed, CAPAs with a stronger chance of remedying the problems first time. Hence an important focus is to seek a significant reduction of repeat observations. This should lead to improved laboratory efficiency supported by right first-time testing and control.

 

Sandle, T. (2022) Managing Workplace Error #3: Dissecting Reasons and Causes of Laboratory Error, IVT Network, at: https://www.ivtnetwork.com/article/managing-workplace-error-3-dissecting-reasons-and-causes-laboratory-error

 

Posted by Dr. Tim Sandle, Pharmaceutical Microbiology Resources (http://www.pharmamicroresources.com/)