United States
Hong KongError prevention
Error prevention works best when it removes the opportunity for error rather than asking for more care. Controls that change the system outperform those that rely on vigilance.
A named knowledge area, and one where the underlying principle answers most questions.
The principle
Controls that change the system beat controls that ask people to try harder. Vigilance degrades under pressure and fatigue; a physical separation does not. Name the risk first.
Options amounting to increased attention, reminding staff, or re-training after an error are the weakest controls and they appear as distractors precisely because they feel responsible. The stronger answer changes something about how the work is done.
Controls, roughly strongest first
| Control | How it works |
|---|---|
| Removing the hazard | Not stocking a concentrated form that is not needed |
| Physical separation | Confusable products cannot be picked by proximity |
| Standardization | One concentration, one process, fewer choices to get wrong |
| Forcing functions | The system will not proceed until something is confirmed |
| Barcode and NDC verification | An unambiguous check that does not rely on reading a name |
| Independent double check | Effective and costly in time, so reserved for high-alert products |
| Auxiliary labels and alerts | Useful, and subject to alert fatigue |
| Education and reminders | Weakest, because it depends entirely on recall under pressure |
Alert fatigue
A system that flags everything trains people to dismiss flags. A question about over-riding alerts is testing whether you understand that too many alerts is itself a safety problem. Vigilance degrades. Systems do not.
The five rights
Right patient, drug, dose, route and time. A useful checklist and, on its own, a weak control - because it depends on someone performing it attentively every time. Too many alerts is a hazard.
On the exam
Identify the specific risk in the stem, then pick the control that removes the opportunity rather than the one that asks for more care.
Common questions
What is the principle behind error prevention?
Controls that change the system beat controls that ask people to be more careful.
Why is "be more careful" never the answer?
Vigilance degrades under pressure. It is the weakest control and appears as a distractor.
What are the strongest controls?
Removing the hazard, physical separation, standardization and forcing functions.
What is alert fatigue?
A system flagging everything trains people to dismiss flags, which is itself a safety problem.
Are the five rights enough?
They are a useful checklist and a weak control, because they depend on attentive performance every time.