Table 3.
Categories of Costs for Safety Interventions
| Safety Initiative | Compliance Costs (Cost to Users) | Administration Costs (Cost to the Organization) | Some Potential Behavioral Distortions (Ways of Undermining the Initiative) |
|---|---|---|---|
| 1. Checklists | Low (simple procedure that takes only a few minutes per operation to complete) | Low (training has been shown to be straightforward; educational materials are available centrally; and copies of the checklist cost only a few cents per patient. Overall cost has been estimated as $11 per patient) (Semel et al. 2010). | Staff might try to complete the checklists for every operation in a single batch at the start of the operating list. Surgical and anesthesia teams might dispense with other safeguards that they previously used (Vats et al. 2010). |
| 2. Crew resource management | Moderate (behavior change) | High (organizing, paying for, auditing, and scheduling CRM training) | Peer pressure not to follow CRM approach; complacency that the “team” is in charge, so individuals are less alert to threats. |
| 3. Joint safety briefings | High (time in preparing and conducting briefings) | Moderate (preparation of briefings and notifications; audit trail of signed briefings) | Briefing skipped or performed in a perfunctory way; overcautious decision making might also be bad for care. |
| 4. Minimum safety requirements | High (more antisocial working patterns) | High (employ additional staff and out-of-hours supplements) | Reclassification of patients as being less acutely unwell. |
| 5. Sterile cockpit rule | Moderate (behavior change) | Moderate (cost of vests, foot-operated signals, wasted time of cleaning staff not using noisy floor polishers etc. while waiting for ward round to finish, etc.) | No one instigates the sterile cockpit rule, and those who do are treated as “overcautious.” |
| 6. Alternation of roles | High (involves significant behavior change) | Moderate (junior doctors may be slower than their senior colleagues) | Increased exception reporting (e.g., operation too complex for junior doctor); token compliance (senior doctor actually runs ward round). |
| 7. Standard layout | High initially (when learning the new layout), then low (standard layout used throughout) | High initially (replacement of trolleys, surgical packs, redesign of anesthetic rooms, etc.), then low (economies of scale from standard layouts) | Staff rearrange layout back to the previous design. |
| 8. Black box | Low (need to enter patients’ details into monitor) | High (recording devices, backup, monitoring) | Staff less willing to use monitoring; staff use mobile phones rather than hospital phones to communicate. |
| 9. Corporate responsibility for training | Low or zero | High (organizing, paying for, auditing, and scheduling training) | Staff stop using their own initiative to arrange training; training becomes less bespoke. |
| 10. First-names-only rule | Moderate (involves a simple behavior change) | Low (dissemination, training, monitoring) | Lack of respect/authority leading to reduced discipline or refusal to obey orders. |
| 11. Incentivized no-fault reporting | Moderate (although tangible incentives for complying) | Moderate (many elements of the system already in place) | Reporting trivial events; system swamped with reports; potential immunity causes clinicians to act with impunity. |
| 12. Bottle-to-throttle rule | Low or zero for most staff | Moderate (dissemination, spot checks) | Increased absenteeism from hung-over staff. |
| 13. Mistake-proofing | Low or zero | High initially (cost of designing, purchasing, and implementing new equipment), then potentially low (fewer medical errors) | Specifically designed to take account of human behaviors but could encourage complacency and overreliance on systems that may not be absolutely fail-safe. |
| 14. Forcing functions | Low | High initially (cost of designing, purchasing, and implementing new equipment), then potentially low (fewer medical errors) | Staff might seek ways of overriding the forcing function. |
| 15. Flight envelope protection | Low or zero | High initially (cost of designing, purchasing, and implementing new equipment), then potentially low (fewer medical errors) | Could encourage reckless behavior. |
Note: High, moderate, and low costs as perceived or anticipated by the authors. Costs would vary according to the characteristics and structure of the health care provider implementing the safety initiative.