To Err is Human


The PTSA education committee organized 2 non-accredited learning activities during PAM. One of them was “Lessons Learned from a Harmful Medication Error: Your Role in Improving Safety” presented by Matthew Grissinger, who is the Director of Education with ISMP.

At the end of my work shift driving back home there are lots of times I think hard “Did I check that right?” and honestly, that thought makes me more tired than the whole work day itself.

This webinar helped me to evaluate my risk assessment at the start of my work day. Medication errors are rarely caused by a single element or a single healthcare professional (HCP). They are the combined effect of latent failures in the system and active failures by HCPs. Catastrophic errors not only lead to patient harm but create second victims, who are the person or persons who suffer emotionally when the care they provide leads to patient harm.

There are 3 types of human behaviors in Just Culture- Human Error, At-Risk Behavior, and Reckless Behavior. To err is human, it is not a behavioral choice and no one is immune to it. BUT:  there are preceding causes of human error like light, noise, climate, humidity, and mental and physical distractions.

Risk identification can be categorized into 2 category-proactive risk assessments: self-assessments (administrative walkarounds, failure mode, and effects analysis) and retrospective risk assessments (pharmacy interventions, technology reports, observation, and event reporting analysis). The primary goals of risk control are to prevent or eliminate errors, make errors visible, and mitigate harm.

Include these 3 goals when building an effective strategy for your workplace:

1.) Error reduction strategies include human reliability which is the least effective and easiest to implement, and

2.) System reliability which is the most effective but hardest to implement. Our workflow should be designed in such a way as to eliminate human error, and

3.) We should nip in the bud any at-risk and reckless behavior of HCPs.


Blog post was written by Neelu Duhan, RPhT at Chinook Regional Hospital.

Neelu is also the promotions director for our PTSA website!


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