Human Error is a social label. It may be characterized as follows

From the Marx primer re: “Just Culture,” define the 4 behavioral concepts integral to understanding the relationship between discipline and patient safety; then apply each of these concepts to the example that Dr. Victoria Rich presents in her video regarding a nurse giving a medication via the wrong route that results in a sentinel event.

• From the Marx primer re: “Just Culture,” define the 4 behavioral concepts integral to understanding the relationship between discipline and patient safety; then apply each of these concepts to the example that Dr. Victoria Rich presents in her video regarding a nurse giving a medication via the wrong route that results in a sentinel event

1- Definition of Human Error
• Human Error is a social label. It may be characterized as follows:
• When there is general agreement that the individual should have done other than what they did, and in the course of that conduct inadvertently causes or could cause an undesirable outcome, the individual is labeled as having committed an error.
• Human error is a term that we use to describe our everyday behavior – missing a turnoff on the freeway, or picking up strawberry ice cream instead of chocolate. The threshold for labeling behavior “human error” is very low – we make errors every day with generally minimal consequences. In the health care profession, we make similar types of errors – perhaps not at the frequency of those in our off-work hours, but often with much more potential for dire consequences. We use terms like mistake, slip, and lapse to basically tell the same story – that someone did other than what they should have done, and inadvertently caused an undesirable outcome. When a physician prescribes the wrong dosage, we will likely label her actions a human error. We understand that the physician did not intend her error or its undesirable outcome even though the consequences are potentially life threatening.
Apply the victoria example,
In Victoria’s example a patient had terminal cancer with an NG, Central line and oral Dilantin. The patient consistently pulls the NG out and the Nurse, who is new, called the doctor. The doctor ordered to put back the NG and gave her Dilantin because she had seizure. The meds is always in the patient room and no one took the oral Dilantin out of the room so the nurse injected the oral syringe in the central line. And then the next day the patient died. So in this case the nurse did intend her error, but she did something that should not have been done. Her action is labled as an a human error

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