The Human Factors: Errors and Skills

Abstract

Despite maximum therapeutic efforts by motivated caregivers, an intensive care patient suffered harm from a medical error and died several hours later as a consequence of a transfusion reaction. At first glance, the cardiology resident is most likely to be identified as the responsible agent. After all, he was the person in direct contact with the patient, he gave orders for the transfusion, and he did not adhere to standard treatment protocols, thus displaying negligence in the transfusion process. A closer look, however, reveals additional factors that contributed to the adverse event: a workload that overwhelmed the resident with several patients requiring a rapidly executed high level of care; staff shortage in the blood bank; the simultaneous arrival of packed red blood cells (PRBCs) for two different patients; and the acceptance of final responsibility for the transfusion on behalf of the nurse. None of these factors alone would have been able to compromise patient safety. Taken together, however, the factors combined and managed to breach the defensive barriers within the system. The unlikely temporal combination of several contributing factors on different levels within an organization created a condition where a single moment of inattention by the resident triggered a deadly outcome. The human error, while quite obvious, was only one link in a longer chain of circumstances.