Avoiding a Second Wave of Medical Errors: The Importance of Human Factors in the Context of a Pandemic

Abstract

The COVID-19 pandemic has had an unprecedented impact on the delivery of healthcare services around the globe. This has resulted in important loss of life for our communities, including health professionals that have been exposed to the disease in their workplace. A human factors approach to the recent changes introduced due to the pandemic can help identify how we can minimize the impact of human error in these circumstances. We hereby present a case study illustrating the application of human factors in the difficult times we are going through at present. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The NCSBN 2022 Environmental Scan: Resiliency, Achievement, and Public Protection

“…As evidence has shown for some time, when humans are caught in a cycle of anxiety, fatigue, and stress, errors are more likely to occur ( Stocking et al, 2021 ; Tejos et al, 2020 ). In a study of critical care nurses that concluded just a few months before the onset of the pandemic, Melnyk et al (2021) found that critical care nurses who reported lower physical and mental health, presence of depressive and anxiety symptoms, and low professional quality of life had a 31% to 62% higher likelihood (odds ratio) of having made medical errors than nurses with better health and a higher professional quality of life.…”

“…Alarms and changes in patient condition went unnoticed due to isolation constraints and were linked to falls and self-extubation, and limited repositioning of COVID-19 patients led to pressure injuries. Tejos et al (2020) describe an incident where a laboratory specimen was mislabeled by a junior nurse who had worked several extra shifts to cover for colleagues who had to quarantine. A culture of safety depends on an organizational climate that creates an atmosphere where staff feels supported and encouraged to report safety issues and concerns ( Alagha et al, 2021 ).…”

“…Several hospitals reported that they believed the increase in central line infections and lower patient satisfaction scores to be a direct result of tired and frustrated staff and the use of travel nurses who were not as familiar with the facility’s policies and procedures (HHS OIG, 2021a). Similarly, a number of studies indicated that the rapid onboarding of nurses impeded adequate training and orientation, further contributing to job stress (ASPR TRACIE, 2021 ; Morgantini et al, 2020 ; Tejos et al, 2020 ).…”

Intensive care digital health response to emerging infectious disease outbreaks such as COVID-19

“…17 Fatigue and stress are well documented contributing factors to medical errors. 18 Real-time data analytics, combined with a highly customisable reporting structure, can support the delivery of high-quality care and reduce the cognitive load on staff, for example, using a ‘FASTHUG’ 19 report to confirm the presence of EHR orders for feeds, analgesia, sedative infusions, thromboembolism prophylaxis, stress ulcer prophylaxis and glucose control for each patient.…”

The impact of COVID‐19 workflow changes on radiation oncology incident reporting

“… 11 Rapidly changing directives, high stress environments, and fatigue are all factors that can contribute to an increased risk of error. 12 , 13 As part of the hospital‐wide COVID‐19 preparedness plan, the Radiation Oncology Department adopted workflow changes to reduce the number of personnel required to be in hospital to perform their duties. For physicians, this meant a drastically reduced number of in‐person patient assessments, even for new consults.…”