Watch out for this turkey - Complacency

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 task.

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. 2002; 3:178-194.

ISMP thanks Anthony F. Grasha, PhD, Professor of Psychology, University of Cincinnati, for contributing this article.