Strategies for Improving Patient Safety: Linking Task Type to Error Type

Abstract

This article reviews the connection between task type (skill based, rule based and knowledge based) and human error. Using real-life examples, each task type and error type is described in detail. Understanding how task type contributes to medical error enhances the ability of nurses to make meaningful changes in health care systems. Through error wisdom, nurses and other health care providers can more successfully navigate health care delivery and ultimately provide safer care to patients.

Reducing Continuous Intravenous Medication Errors in an Intensive Care Unit

“…Lapses were a result of memory failure such as forgetting to unclamp the roller when hanging a continuous infusion pump. 4 Seventy-eight percent of medication errors that occurred in the ICU were serious and life-threatening. Suggested approaches to reduce medication errors in High Reliability Organizations were to standardize practices and invest in training programs.…”

Nursing Errors: A Study of the Current Literature

“…Among the various ways to avoid errors, the following were highlighted: -Improvements in the nursing work process, understanding it as complex, hampered by working conditions, especially due to the high demand for care, work overload and insufficient remuneration; [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] -Continuing education at work as an effective method to prevent adverse events; …”

“…45 The highest frequency of errors was detected in the Hospitalization Units, 13,[18][19][26][27]30,32,37,43 in the Intensive Care Units (ICU) 20,23,28,30,42 and in pediatrics. 15,17,29,41 This can be explained by several factors related to the characteristics of users and the specificities of these units.…”

“…The human factor, i.e., the nursing professionals themselves, also carry the burden of the causes of errors, and the most frequent causes attributed to the individual staff and professional are: distraction , 16,19,[21][22]27,38,42,44 communication failures [13][14]17,[24][25][26][27][28][29][30][31][32][34][35] and lack of knowledge. 14,[17][18][19]21,[29][30]32,34,38,44 Distractions and communication failures are reported in other studies as factors that may predispose the occurrence of errors during care, since distractions take the professional from the focus, which at that moment is the patient, and efficient communication between the team can minimize and even prevent errors.…”

The Wicked Question Answered

“…But I would certainly get the palliative care specialist and the physician together on providing adequate orders for adequate medication to meet the dying patient's needs'' and ''As long as suffering is not an outcome. 2 This is similar to the wicked question asked by this study as some rules intended to fit the situation do not meet exact clinical situation specifics. Despite prominent attention in the critical care setting, end-of-life care remains a challenge for the bedside critical care nurse, and key issues are a need for greater discussion and understanding of the roles and motivations of health professionals and families concerning end-of-life care as well as improved communication skills when engaging in end-oflife discussions across the health care community.…”