Like rotten eggs makes leak quickly noticeable or

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like rotten eggs, makes leak quickly noticeable) or (administration of anesthesia involves intubating patient - important to ensure patient is correctly intubated with tube going into trachea (windpipe) and not esophagus (food pipe) - solution is capnometry, detection of carbon dioxide expired during expiration) Mitigation Successful error detection leads to trapping error or mitigating consequences (trapping error refers to catching an error in a process and preventing process from continuing to an incorrect chain of activities - in event an electrical circuit gets overloaded, safety fuse will trip and trap ‘error’ of overloaded circuit) If error not trapped, need to take care that adverse effects consequent to error are minimized - mitigating adverse effects is accomplished by variety of techniques : Redundancy (process of duplicating critical controls such that catastrophic results are avoided - example is patient behavior in making critical healthcare decisions, many patients seek second opinion from different physician to confirm opinion of first physician); incorporating fail- safe modes of operation (if system fails, then should fail in manner that does not cause injury/ death - consider design of cardiac pacemakers which can be affected by radiofrequency interference,
in event pacemakers are protected by being programmed to revert to fixed rate when RFI is detected) o Limitation of mistake-proofing Errors originate in skill-based, rule-based, or knowledge-based actions - when steps in activity have to be carried out in repetitive manner, skill- based/ rule-based actions can be designed into products and procedures, however, designs to prevent mistakes are themselves fallible Redundant systems and multiple error-proofing approaches may be required in critical areas - activity involves situation that has not been encountered before, need knowledge-based actions (situation is new, no standard operating procedures to be routinely followed) whereas knowledge-based actions require approach involves assessing situation, understanding problem, considering alternative solutions, selecting one solution and executing solution (involves human capabilities to a much greater extent) Most manufacturing tends to be routine, repetitive and predictable - worker dealing with same kind of raw materials, inputs, equipment, tools and processes, but health care environment is complex (each patient is unique and presents different profile - patient is unique because things are not normal or routine) In manufacturing, greater likelihood of applying skill-based or rule-based actions while in healthcare, more likely to need knowledge-based actions - greater need, in healthcare, for professional to apply expert knowledge to situation at hand - consider question, is pharmacy a knowledge-based profession? In 1970, Jamous and Peloille suggested that w ork has two dimensions: technicality and indeterminacy ( technicality is rule-based approach to decision making, while indeterminacy is more knowledge-

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