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Safety checks - a healthy habit

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checksLike any human activity, checking is part of personality and behaviour. There are several psychological factors relevant to patient safety, including memory, prospective memory, automaticity, and responsibility.

Checking is a prescribed part of patient care. Many checks on a patient and equipment will be performed during one hospital admission. Some may be standard but unwritten practices; others such as medicines and blood transfusion are laid down in national professional and official guidance. These include:

  • Background checks – such as making sure equipment is ready for use or that essential items are available.
  • Immediate pre-procedure checks – for instance, verifying a patient's identity before surgery.

The latter is more important because it allows errors earlier in the causation chain to be detected and avoided. It is difficult to establish those adverse events to which checking failures might have contributed, however, some errors are undoubtedly preventable by more thorough checking.

Psychological factors relevant to checking behaviour

Solutions to medical errors do not lie explicitly within medicine but in psychology and human disciplines. Like any human activity, checking is part of personality and behaviour. Propensity for checking varies from individual to individual.

Memory

Memory plays a part in checking. Individuals must remember to perform checks and be confident they have been completed.

Prospective memory

Prospective memory describes human ability to remember and perform actions after a delay. Most commonly, the intention to perform an action is followed immediately by the action, but a delay between intention and action is not unusual. Prospective memory enables humans to resume tasks after interruptions as well as keeping track of what they still have to do. However, this mechanism can fail when an unexpected interruption diverts their attention and prevents them from explicitly encoding an intention to resume. Multitasking – simultaneous parallel processes – puts a heavy burden on prospective memory. This error type is highly relevant to healthcare workers because delays and interruptions occur frequently.

Automaticity

Automaticity is used in psychology to describe a process that takes place largely independent of conscious control and attention. It describes the skilled action that people develop through repeatedly practicing the same activity; for example driving a car. Automaticity has been implicated in healthcare errors also. Checking protocols, for example, may demand close attention, but only superficial attentiveness may actually be paid in practice.

Responsibility

An individual’s responsibility can affect checking performance. Some clues may be gained from obsessive-compulsive disorder studies, where inflated responsibility plays a significant role in compulsive checking. Inflated responsibility, perceived harm, and perceived probability of harm interact to produce checking behaviour. Temporarily reducing responsibility feelings reduces compulsive urges.

Shared responsibility effects on checking have been widely studied. An individual's effort on a particular task will diminish as group size increases, thereby reducing self-motivation to complete the task. This motivation loss, later termed “social loafing”, suggests that an individual will exert less effort when working collectively on a task compared to working alone.

Single versus double-checking

Again, at first sight, two-person checks should offer added safeguards over and above single-person checking, but this assumes that the checks are done properly by both parties. There is little evidence to determine which is more effective. Paradoxically such safety procedures may provide less, rather than more, assurance, as two staff may rely on each other to be rigorous, resulting in neither giving the task their full attention.

"Despite or perhaps because of its ubiquity and apparent simplicity, checking is little studied either in general or industrial contexts."

Increasing checking effectiveness

Checklists

Healthcare relies heavily on healthcare professionals' ability to recall critical information during medical emergencies. However, memory is likely to be error prone, resulting in planning and execution failures. Many industries, including aviation, railway maintenance, and nuclear power, attempted to overcome this particular limitation by mandating checklists.

Additionally, the highest probability is that the first item on the checklist will be successfully completed and a probability that completing subsequent items without interruption diminished as time progresses. It is recommended that highly critical items go first on the checklist. Furthermore, duplicating a few highly critical items may be advantageous. The following principles enhance the relevance in a healthcare context:

  1. Checklist responses should portray desired status or item value.
  2. Fingers should touch or point to an appropriate item while conducting the checklist.
  3. A long checklist should be subdivided into smaller chunks, associated with systems and functions.
  4. Sequencing checklist items should follow “geographical” organization and be performed in a logical flow.
  5. Checklist items should parallel internal and external activities (may conflict with number (4)).
  6. The most critical items on the task-checklist should be listed as close as possible to the beginning of the task-checklist (may conflict with number (4) and (5), if so then (6) should take precedence).
  7. Critical checklist items needing re-setting owing to new information should be duplicated.
  8. Completing task-checklist call should be written as the last item.
  9. Checklists should be designed so that their execution will not be tightly coupled with other tasks.
  10. Individuals should be aware that the checklist procedure is highly susceptible to production pressures.

Physical prompts and clues

Physical reminders should be based on sound psychological principles. Good reminders should be:

  1. Conspicuous.
  2. Contiguous (as near as possible to the action).
  3. Provide context.
  4. Have sufficient information.
  5. Enable staff to count off tasks.

“Bad” reminders add complexity, and can be an irritant to the practitioner doing the checks.

Recommendations

Despite or perhaps because of its ubiquity and apparent simplicity, checking is little studied either in general or industrial contexts. Relevant psychological constructs may echo everyday experience but have largely been investigated in the laboratory. In view of lack of real-world evidence, recommendations have to be made with caution. Evidence regarding single versus two-person checking is inconclusive. Checklists and reminders should be based on established theoretical principles. Another important practical point is that risk assessments for new developments should be performed. In industrial settings, this begins as a prospective process before new techniques or technologies are introduced (even at the stages where introduction is first considered, as part of the initial option appraisal). The process continues after implementation, as adverse incident data are analysed. This contrasts with the introduction of NHS policies and procedures. Occasionally, new safety initiatives may not always have the desired effect and their unintended consequences may become apparent if such prospective processes are not followed. It is clear that there is much to learn regarding factors that influence healthcare checking procedures and performance. We suggest that examining the following gaps could improve practice:

  1. Relationships between checking and personality should be explored.
  2. How does training influence checking behaviours for those who are not naturally inclined to check?
  3. Empirical work on single versus double-checking merits should be undertaken, ideally leading to concrete outcomes.
  4. How “mindfulness” might be promoted in healthcare to counteract automaticity.
  5. It would also be useful to understand what reminder/checking strategies healthcare staff already use in their day-to-day work routines.
  6. Additionally, there may be some methodological benefit from developing a more detailed and robust checking and checking procedure taxonomy.
  7. Further testing psychological theories in “real world” settings would be useful.
  8. The potential for using formal task analytical methods when introducing new processes should also be explored.
  9. Comparing approaches involving checking from other high-risk industries with healthcare experiences may be a fruitful.
  10. Finally, understanding that “safety culture” is an important organisation identity aspect proves useful when considering the impact of introducing new checking safety measures.

January 2010.


This is a shortened version of “Checking in healthcare safety: theoretical basis and practical application”, which originally appeared in International Journal of Health Care Quality Assurance, Volume 23, Number 8, 2010.

The authors are James Shillito, Konstantinos Arfanis, and Andrew Smith.