Summary Incident investigation for pharmacy

Incidents
Types of human error
 skill-based performance
o that are relatively simple and well-practiced
o Individuals rely on their motor skills and procedural memory
o e.g. misreading a prescription and counting days rather than tablets
 rule-based performance
o individuals apply a set of rules or guidelines to solve problems or make
decisions
o typically acquired through training or instruction and dictate a specific course
of action based on circumstances
o e.g. a medicine is contraindicated for a patient
 knowledge-based performance
o highest level of performance and involves tasks that require problem-solving
and decision-making based on an individual's understanding
o e.g. substitute the wrong brand for a generic
Why do skill-based error happen?
 sign or label incorrect
Why do rule-based errors happen?
 may misinterpret or misunderstand the rules
 individuals may rigidly adhere to rules without considering the specific context or
circumstances of the situation
Why do knowledge-based errors happen?
 situation not fully understood
 information incorrect at source or through decision maker’s interpretation
 cognitive biases, such as confirmation bias or anchoring bias, can influence how
individuals perceive and interpret information
What is a procedural violation?
 intentional deviation from the rules
 different from rule-based error which is unintentional
 most violations are not intended to cause harm
Types of violation
 routine
o become a part of every day practice
o out of habit
o e.g. dispensing against a label rather than a prescription
 optimising
o fulfil goals that are secondary to the task
o making it less effortful or more pleasant
o e.g. selling OTC for a patient for longer than you should
 situational
o situation is felt to require it
o e.g. accuracy checking procedure but under time pressure you miss out steps
 exceptional
o novel situation arises
o rules are judged to be unsuitable