Insights into people will improve
our safety systems.
From the June 28, 2001 issue
Today, it is widely recognized that system failures cause
errors and that well-designed systems and technology offer
the best chance of preventing errors. But, has our growing
attention on systems and technology caused us to overlook
interventions that can improve human cognitive function? While
we are beginning to better understand healthcare systems,
have we devoted equal attention to understanding how the human
mind operates and the conditions that adversely affect its
function? Have we done enough to identify stress-producing
aspects of complex systems and steps to help people cope with
them? Do we consider how personal beliefs, values, and attitudes
influence performance? Tony Grasha, Ph.D., Professor of Psychology
at the University of Cincinnati, recently studied cognitive
functions and psychosocial factors that impact the accuracy
of outpatient pharmacists.1 His research suggests tools that
can enhance memory and sensory input while taking into account
environmental factors and organizational dynamics such as
supervisory practices, as well as personal qualities such
as demeanor, patience, ability to manage stress, and interpersonal
relationships. Here's a sampling of what he found with specific
· Periodic self-monitoring and deferred verification: Errors
were reduced by 21% when pharmacists periodically monitored
themselves to detect errors. Each subsequent check identified
95% of errors that were missed during a prior check. However,
mistakes were detected less frequently as the amount of continuous
time spent on the specific activity increased. Thus, taking
a short break or changing to a different task before self-monitoring
· Light and magnification: Errors were reduced by 16% when
pharmacists were given a high intensity task light and magnification
lens to read prescriptions.
· Copyholders: Errors were reduced by 24% after installing
a device to hold prescriptions on the computer monitor, closer
to eye level, to improve the visual angle during order entry.
· Alerts: Posting alerts in strategic locations with 30 error-prone
products reduced errors with these products by 71% and potentially
significant occurrences by 45%. Errors with non-targeted drugs
also were reduced by 56% simply through heightened error awareness.
· Exaggerated product labels: Errors were reduced by 35%
after affixing product sleeves with exaggerated, non-conventional
type fonts to better read sections of drug names/doses.
· Cognitive style and coping skills: Pharmacists who could
attend to details and focus their attention made fewer errors.
About 12% of pharmacists had difficulty with details and focus,
and they accounted for 33% of the all the mistakes observed.
High intensity lights, copyholders, and exaggerated product
labels were especially helpful for such people. Pharmacists
with adequate coping skills and stress management training
also made fewer errors.
· Workload: Pharmacists were more vulnerable to mistakes
under low workload conditions and when shifting from high
to low activity. Boredom, reduced task focus, and disruptions
in personal work rhythms made it hard to focus on tasks, even
though pharmacists with both low and high workload were equally
concerned about their performance and motivated to do well.
While, of course, there are limits to a desirable level of
workload, a single standard is unlikely given that people
have different thresholds.
· Breaks: Pharmacists who perceived that break times were
adequate and available made fewer errors and detected more
errors during self-monitoring.
· Supervision: Pharmacists who made fewer errors had supervisors
who fostered appropriate autonomy and were perceived as being
democratic, facilitative, and helpful in setting goals. Pharmacists
who made more errors had supervisors who were perceived as
overly autocratic and punitive. Supportive supervisors who
interacted well with their staff lowered stress levels and
allowed staff to better focus on tasks at hand.
· Feedback and goal setting: Pharmacists who received constructive
feedback about errors from the research team, and who established
goals to enhance error detection, were able to improve their
ability to detect and prevent errors by 103%. After two weeks,
pharmacists were asked to set a goal to either maintain their
current performance or improve their ability to detect mistakes.
Compared with a control group where no feedback was provided,
even those who set a goal to maintain current performance
increased error detection by 22%. Instead of comparing one's
performance to others, establishing personal improvement goals
combined with constructive feedback about errors proved quite
beneficial. Interestingly, pharmacists ranked feedback and
goal setting among the most effective strategies investigated
by the researchers.
These interventions are not uniquely suited to pharmacists
alone. The same cognitive factors influence all people in
all environments. While differences in specific facilities,
processes, and individual makeup can influence the success
of these interventions, they are widely applicable in a broad
context. According to Grasha, ongoing understanding about
how people react to systems and integrate them into their
mental structures will enable us to find new ways to enhance
workflow, physical work spaces, sensory input, and memory;
identify new applications for technology; and improve training
for supervision, conflict resolution, and stress management.
In the long run, such interventions will lead to increased
professional satisfaction, workforce retention, enhanced efficiency
and productivity, and improved patient care and safety.
* Reference: 1. Grasha A. A cognitive systems perspective
on human performance in the pharmacy: implications for accuracy,
effectiveness and job satisfaction. Executive Summary Report.
Alexandria (VA): National Association of Chain Drug Stores;
2000 Oct. Report No. 062100. Send email requests for the document