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The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Abstract
Human beings are error prone. A significant component of human error
is flaws inherent in human cognitive processes, which are exacerbated
by situations in which the individual making the error is distracted,
stressed or overloaded, or does not have sucient knowledge to
undertake an action correctly. The scientific discipline of human factors
deals with environmental, organisational and job factors, as well as
human and individual characteristics, which influence behaviour at
work in a way that potentially gives rise to human error. This article
discusses how cognitive processing is related to medication errors.
The case of a coronial inquest into the death of a nursing home resident
is used to highlight the way people think and process information,
and how such thinking and processing may lead to medication errors.
Authors
Heather Gluyas, post-graduate lecturer in patient safety, quality and
clinical governance, School of Health Professions, Murdoch University,
Perth, Australia.
Paul Morrison, dean, School of Health Professions, Murdoch
University, Perth, Australia.
Correspondence to: h.gluyas@murdoch.edu.au
Keywords
Case study, drug calculations, education, errors, human factors,
medication, medication errors, patient safety
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The inquest
In March 2013, a coronial inquest was held
into the death of a nursing home resident in
Australia. The coroner found that the cause of
death was related to underlying disease and that
no person contributed to his death. However,
in the course of the inquest it was established that
a medication error had occurred in the hours
preceding the residents death, involving the
subcutaneous administration of 25mg of morphine
instead of 2.5mg.
The coronial report identified that the nurse
involved was a new graduate, working her second
shift as a registered nurse at the nursing home.
The nurse had not undergone the requisite two
days orientation or buddying required for new
members of staff at the nursing home. During
the shift in question, the nurse was in charge,
working with three extended care assistants
(nursing assistants). There were 36 residents,
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Medication errors
Errors are common in health care. Studies
identify that one in ten patients will experience
an adverse event as the result of an error. One in
five of these will experience severe injury and
one in 30 will die (Wilson et al 1995, Wilson
and Van Der Weyden 2005, World Health
Organization (WHO) 2005. Medication errors
are a significant contributor to adverse events,
being the second most frequently reported error
(Wachter 2012). By reviewing the case presented
above it is possible to identify the active error
as the administration of the incorrect dose of
morphine. The cognitive factors that may have
influenced the active error relate to all three types
of cognitive performance (Table 1).
TABLE 1
Cognitive performance factors related to the medication error
Cognitive performance
Example
Skill-based
Rule-based
Knowledge-based
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Conclusion
The coroners inquest findings related to the case
described in this article cleared the nurse who
made the medication error of involvement in
the subsequent death of the resident. However,
a medication error occurred during the care
of that resident. Humans are unique in their
ability to solve problems, multitask, and manage
complicated tasks and complex situations.
The way humans function cognitively and
process information permits this to happen, often
without conscious attention. However, these
same processes also make humans error prone.
Recognising this in terms of health care is vital
as it provides the opportunity to increase patient
safety by focusing on strategies that decrease
cognitive load and decrease the likelihood of
error. The discipline of human factors seeks to
understand what makes people error prone, and to
design systems, processes, work environments
and technology that lessen the likelihood of
human error NS
References
Australian Commission on Safety
and Quality in Health Care (2013)
Recommendations for Terminology,
Abbreviations and Symbols used
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Reid-Searl K, Moxham L,
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