Watch out for this turkey - Complacency
From the November 27, 2002 issue
trust, contentment, and familiarity describe the slow but predictable
arrival of complacency on the job. It almost always occurs in
the most reliable, safe, and productive parts of an organization,
particularly where automation or technology are present. But
complacent reliance on technology can lead to betrayal by the
mechanical and electronic equivalent of a "good friend."
Consider the following example. A pharmacist receives and
enters an order into the pharmacy computer. A nurse in the
patient care unit types the patient's name on the automated
dispensing cabinet keyboard and selects the drug that matches
the patient's name on the screen. A matrix drawer opens and
she is directed to a specific coordinate to retrieve the dose.
About 99.99% of the time, everything works out as planned.
With such a high degree of accuracy and knowledge that the
cabinet is "computerized," it is understandable
that the nurse believes nothing could go wrong. Unfortunately,
that trust can be broken easily if the pharmacy technician
places the drug in the wrong matrix when restocking the machine.
Then the nurse could open the right drawer, take a dose from
the proper coordinate, quickly glance at the label, but fail
to notice that it's the wrong product. This familiar "grab
and go" manner of drug administration contributes to
the mental bias that the right drug is being delivered.
The use of bar coding for inventory and drug administration
could help, but experience with automated dispensing technology
suggests that caution is needed. Even though the barcode on
a drug container is matched with the proper matrix location
of an automated dispensing unit, loading the equipment is
a manual operation so errors are possible. Thus, technicians
might scan the barcode on a zip-lock bag of unit dose medications
for verification and entry to the drawer, then grab the rest
of the products in the bag and load them without checking
their labels. If the zip-lock bag contained any erroneous
medications or strengths, stocking errors are possible, even
with bar coding.
To best handle complacency, one needs to first understand
the human factors involved. Complacency is embedded within
a mental bias that allows our experiences to guide our expectations.
The mental resources needed to process information are reduced
by this shortcut since present circumstances are normally
a good match to past occurrences. Thus, mental resources are
devoted to the more interesting and complicated parts of a
Fortunately, there are a few things we can do to make complacency
less of a problem. You can begin by increasing awareness about
the adverse effects of complacency and counter the belief
that "It can't happen to me." Use prompts to remind
people of errors that could occur when blindly trusting automation
and technology. Encourage staff to periodically monitor their
work with technology and automation to identify personal patterns
of thinking and behaving that are likely to fuel complacency.
A staff meeting might be devoted to sharing these observations
so that common issues can be identified. Use the primary discussion
points to develop specific plans to work on issues where complacency
could lead to errors (e.g., stocking of drug dispensing equipment;
the "grab and go" method of drug administration
when busy). Finally, consider placing artificial errors in
the system to test when and where errors due to
complacency are likely to emerge. However, to prevent an artificial
error from reaching a patient, be sure to establish and follow
strict institutional guidelines for such tests and carry them
out in a controlled setting (e.g., simulations of order entry
for erroneous medication orders to determine effectiveness
of computerized messages to truly alert staff to the problem).
Involve staff members in helping to interpret the test findings
and suggest solutions to problems.
Reference: Young MS and Stanton NA.
Attention and automation: New perspectives on mental underload
and performance. Theoretical Issues in Ergonomics Science.
ISMP thanks Anthony F. Grasha, PhD,
Professor of Psychology, University of Cincinnati, for contributing