Shannon Bakon & Sharon Ragau

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1302 – Halt! Incident management: Increasing awareness of humanistic factors

Background
Humanistic factors that can contribute to errors in a hospital ward include staff experiencing hunger, anger or upset being late and tiredness or fatigue. There were 104 incidents within a general medical ward over a 2 month period. These incidents were categorised as Human Error Incidents which comprised 57.7% (n=60) of all incidents and communication/ documentation incidents 51.9% (n=54%).

Aim
The aim of this initiative was to increase nursing staff awareness of humanistic factors that contribute to errors and thereby decrease ward incident rates.

Method
Regular staff education sessions, posters, and raising the awareness of HALT (Hungry, Angry, Late, Tired) within the morning staff meeting was conducted over a two month period.

Results
The rate of incidents reduced to 71 in the following two month period. This signified a total reduction of 31.7%. Human error incidents decreased to 32.4% (n=23) of all incidents indicating a reduction of 25.3% from preceding two months. Incidents relating to communication /documentation errors reduced to 28.2% (n=20) of all incidents indicating a reduction of 22.9% from the preceding two months.

Conclusion
Raising awareness of the humanistic factors that contribute to errors can assist in reducing preventable incidents. Recognition of these factors is important in creating a safe environment and in ensuring patient safety.

Key words: Human error; Nursing, medical; incident; patient safety.