Are the MS16A's the ones that people were getting confused - I recall someone saying that there were some incidents of mixing 1hr syringe drivers with 24hr syringe drivers... as per the warning on page 86 of the
guide We can say this confusion should never occur as people should be aware of the differences, be fully trained, have time to think and check everything they do and focus on what they're doing without interruption. However, it seems this utopia rarely exists, and in rare cases error gets through the safety checks and alarms and things go wrong. It's probably true that human error cannot be eliminated but there are things that can increase and decrease its likelihood. Human error is a term that is used broadly and sometimes people use it too readily to blame 'lazy' users when really the system and devices need to be thought about as well.
(From the perspective of our project we probably have a bias toward not blaming the user but trying to understand why the error happened (in terms of device design, cognition, and the context), often because other 'normal' people in the same situation would have done the same)
I must admit that converting between 'ml' and 'mm' sounds like a nightmare to me. I'm not sure what's involved at this stage - but my intuition is the less conversions and calculations the better. The volumetric devices that do most of the calculating for you seem friendlier. It'd be nice if the prescriptions included the exact information that is needed for the device to reduce the translations and calculations nurses have to do. I think this would reduce the likelihood of error.
There was an important point made about dumbing down work as the devices do things for you e.g. the calculations. Here we become more and more reliant on the technology... we're pretty stuck if the battery runs out on our mobile phones as we don't know the actual numbers any more, and I am sure more people get more lost when their SatNavs fail. However, this can also allow us to do more. A nurse raised the point with me that they do a lot more nowadays... when she started the max amount of infusions per patient was more like 2 or 3, in the most extreme case she had 15 pumps hooked up to a patient and was managing them on her own. Real consideration needs to be given to doing more, doing simpler, and deskilling people... you might make the system more efficient but it might be less resilient and more prone to error.
The issue of feeling safer and taking less care reminds me of people reducing visibility at roundabouts, i.e. they would plant hedges so as you approached a roundabout you were unable to see oncoming traffic, therefore you were more likely to actually stop. With better visibility people take more risk as they look ahead, anticipate and squeeze into the traffic. Ironically then the safer system is less usable, less efficient.... again careful consideration needs to be given here. It does emphasise thinking about the system holistically to make it safer.
James Reason has come up with a '
three bucket ' model which I think nurses are meant to use to be more aware of 'risk'. Basically the more proverbial in the buckets the riskier the situation and the greater need to back off, think and get help. (I'm not sure if there are plans to incorporate a fan into this model
)
