2021_Book_TextbookOfPatientSafetyAndClin

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• A routine violation is basically cutting corners
for one reason or another, perhaps to save time
or simply to get on to another more urgent
task.
• A necessary violation occurs when a person
flouts a rule because it seems the only way to
get the job done. For example, a nurse may
give a drug which should be double checked
by another nurse, but there is no one else available.
The nurse will probably give the drug,
knowingly violating procedure, but hoping
that this is in the patient’s interest.
• Optimising violations which are for personal
gain, sometimes just to get off work early or,
more sinister, to alleviate boredom, ‘for
kicks’. Think of a trainee surgeon carrying out
a difficult operation in the middle of the night,
without supervision, when the case could easily
wait until morning. The motivation is
partly to gain experience, to test oneself out,
but there may be a strong element of the
excitement of sailing close to the wind in defiance
of the senior surgeon’s instructions.
In practice, the distinction between slips, mistakes,
and violations is not always clear, either to
an observer or the person concerned. The relationship
between the observed behaviour, which
can be easily described, and the psychological
mechanism often hard to discern. Giving the
wrong drug might be a slip (attention wandered
and the doctor picked up the wrong syringe), a
mistake (misunderstanding about the drug to be
given), or even a violation (deliberate over sedation
of a difficult patient). The concepts are not
easy to put into practice, except in circumstances
where the action, context, and personal characteristics
of those involved can be quite carefully
explored.
3.4 Understanding the Influence
of the Wider System
Human beings have the opportunity to contribute
to accidents and clinical incidents at many different
points in the process of production and operation.
Problems and failures may occur in the
design, testing, implementation of a new system,
H. Higham and C. Vincent
its maintenance and operation. The most obvious
errors and failures are usually those that are the
immediate causes of an accident, such as a train
driver going through a red light or a doctor picking
up the wrong syringe and injecting a fatal
drug.
The immediate causes described above are the
result of actions, or omissions, by people at the
scene. However, other factors further back in the
causal chain can also play a part in the genesis of
an accident or a serious clinical incident. These
‘latent conditions’ lay the foundations for accidents
in the sense that they create the conditions
in which errors and failures can occur [5]. This
places the operators at the sharp end in an invidious
position as James Reason eloquently
explains:
Rather than being the instigators of an accident,
operators tend to be the inheritors of system
defects …their part is usually that of adding the
final garnish to a lethal brew whose ingredients
have already been long in the cooking [4]
The organisational accident model applies this
perspective to the study and analysis of accidents
in many complex industries [5]. The accident
sequence begins (from the left) with the negative
consequences of organisational processes, such
as planning, scheduling, forecasting, design,
maintenance, strategy, and policy. The latent conditions
so created are transmitted along various
organisational and departmental pathways to the
workplace (the operating theatre, the ward, etc.),
where they create the local conditions that promote
the commission of errors and violations
(e.g. high workload or poor human–equipment
interfaces). Many unsafe acts are likely to be
committed, but very few of them will penetrate
the defences to produce damaging outcomes. The
fact that engineered safety features, such as
alarms or standard procedures, can be deficient
due to latent conditions as well as active failures
is shown in Fig. 3.1 by the arrow connecting
organisational processes directly to defences.
The model presents the people at the sharp
end as the inheritors rather than as the instigators
of an accident sequence. Reason points out that
this may simply seem as if the ‘blame’ for
accidents has been shifted from the sharp end to
the system managers. However, managers too are