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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 interventions:

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 increases effectiveness.

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 to

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