Why can’t staff just be more careful?

This sign may represent current health care safety strategy:


‘When faced with a human error problem you may be tempted to ask ‘Why didn’t they watch out better?’ How could they not have noticed?’ You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. They are all expressions of the ‘Bad Apple Theory’ where you believe your system is basically safe if it were not for those few unreliable people in it. This old view of human error is increasingly outdated and will lead you nowhere.’ – Sidney Dekker.

Current health care safety lends upon ‘Bad Apple Theory’ relying on alerts, education and policies in response to adverse events.

The NSW Health Alert after the St George Epidural tragedy outlines essential procedure when using antiseptic solutions.

The human factors approach, however, teaches us this alert and procedure has not created a safe system.

The Root Cause Analysis performed after the St George event requested antiseptic solutions be distinctly coloured. There have been no reports of mistaken administration when distinct chlorhexidine is used. Front line staff do not want indistinct chlorhexidine in hospitals. We understand slips and lapses occur and it is ‘human to err’. We fear for our patients and fear for ourselves becoming the next ‘second victim‘.

Given that banning indistinct chlorhexidine appears a simple safety solution, why hasn’t this already been done?

Perhaps legal ramifications and the repercussion from manufacturers makes regulating bodies (TGA, FDA, MHRA etc) hesitant to act.

How do we instill courage in regulating authorities to provide us with safer work environments?

When indistinct chlorhexidine is banned know that this has happened (sign the petition here). We will have gifted ourselves with frameworks to optimise patient safety.


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