Question

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you guess was the biggest contributor to this error?

(A) The nurse's training was out-of-date.
(B) The nurse was prone to error because she was tired.
(C) The nurse had become complacent and stopped trying hard.
(D) The nurse deliberately ignored protocol.

Answer 1

Fatigue is likely the main contributor to the medication error made by an experienced nurse at the end of a double shift. Working consecutive shifts can lead to impaired judgment, and these risks can be mitigated by managing work hours and rest periods.

Step-by-step explanation:

When analyzing an incident where an experienced nurse gave medication to the wrong patient at the end of a double shift, human factors principles suggest that fatigue is likely the biggest contributor to this error. The critical thinking question posed addresses the issue of how healthcare professionals often work rotating shifts, which can be problematic due to the disruption of natural sleep patterns and the potential for fatigue. This can lead to decreased alertness and impaired judgment, which are known risk factors for making mistakes.

In the scenario described, considering that the nurse had an excellent track record, it is less likely that outdated training (A) or complacency (C) is the issue. The fact that the error occurred at the end of a double shift strongly suggests that tiredness (B) due to an extended period of work was the main factor, rather than a deliberate violation of protocol (D). To mitigate such risks, adequate staffing levels, allowing for appropriate breaks, and ensuring reasonable work hours are crucial strategies.