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The Human Side of Error Vulnerability


By Laura Gayton, RN, Associate Director, Standards Interpretation

It may sound oversimplified, but an understanding of human factors may be the best tool for assessing standards compliance.

When you think about it, human existence and human error go hand-in-hand. We can make an impact in safety performance by mastering some basic concepts of human factors, such as:

  • inherent behavior
  • characteristics
  • needs
  • abilities
  • limitations

All of this is complemented by a strong grasp of what constitutes a safe working culture.

Importance of Surgical Safety Checklists
While there is no way to ever eradicate human error, it’s possible to lessen its impact by using strategies such as checklists. Nowhere is this better illustrated than in an ambulatory surgery center (ASC). The environment is hectic, and staff must manage patient needs in a complex (and often loud) environment, with distractions ranging from:

  • alarms
  • ringing phones
  • equipment
  • computers

I can attest firsthand to the task switching that occurs in the ASC after many years as a perioperative nurse. In the midst of all the noise, staff must multi-task between:

  • set up
  • counting
  • specimen management
  • discussions with patients or the surgical team

This is the exact situation where a checklist comes in handy. The Surgical Safety Checklist developed by the World Health Organization (WHO) makes it easier to identify distractions and document procedures. This was literally designed with the same goal as the pre-flight checklist: to relieve the pilot of the burden of memorizing everything. Realizing the limitation of human memory, the Surgical Safety Checklist was released in 2007 so a perioperative team member would also rely on a pre-operation checklist to complete tasks prior to a surgical procedure. The WHO checklist was developed to:

  • enhance communication between surgical team members
  • improve outcomes
  • decrease complications
  • improve patient safety

Task Study
A good starting point in considering human factors is simply reviewing the task. In the surgery example, consider the timeframe during a surgical wound closure and time allotted for accounting for instruments, sponges and needles. This takes a lot off the nurse’s plate and also drastically reduces the possibility of a surgical error.

Situational awareness tells us that a busy work environment lends itself to human error and this was behind the design of the checklist. Alarms are unlikely to disappear from AHCs but it's imperative for the surgical team to communicate clearly. Otherwise, poor communication can quickly result in a surgical site infection or other adverse event.

Limiting Distractions
By limiting distractions, organizations are also limiting their vulnerability to an error. The Association of PeriOperative Registered Nurses (AORN) released a position statement on managing distractions and noise during perioperative care and endorses a multidisciplinary team approach to create a safer operating room (OR) environment. The same logic holds true today that a “no-interruption zone in which non-essential activities are prohibited” keeps noise to a minimum. AORN recommends that organizations clearly identify non-essential activities prior to surgery.

All of this reduces the human cognitive workload. Workflow functionality should aim to be seamless and offer few disruptions, supporting the idea that standard work and workflow processes can greatly reduce error. Decreasing or eliminating sources that cause error or enable safety issues helps to reduce vulnerability to human error. These days, the technology is there to support this.


Health care organizations can incorporate identifying human factor vulnerabilities within their commonly used analysis methods. Root cause analysis is a structured analytical tool used to address surgical errors after they occur. Failure mode and effects analysis (FMEA) is a useful process to identify and address potential problems and their effects before an adverse event occurs. By using these methods, health care organizations can evaluate systems and processes with human factor considerations in mind to effectively identify vulnerabilities and implement human factor-based solutions that ultimately promote safety and mitigate risk.


Laura Gayton, MHCA, BSN, CSSM, CNOR, is Associate Director at The Joint Commission and currently a candidate on AORN's national ballot for secretary. Prior to this, she held positions as Director of Perioperative Services for Amita Resurrection Hospital and Clinical Nurse Manager at Barnes Jewish Hospital.