Patient Safety Awareness Week: Stop. Think. Act. Review.

March 16, 2022  //  FOUND IN: Updates & Resources

Self-checking is a habit of the mind that keeps our attention on task. The STAR technique is a tool for developing strong self-checking habits. 

Stop: Pause for at least 1 second 

Think: About your act 

Act: Perform the act 

Review: Check for response 

How should we use this tool? 

Use self-checking when processing information such as reading a label, flow-sheet, warning sign, posting, computer screen, indicator, etc. Use self-checking when doing things with your hands such as entering data, documenting, connecting devices, selecting supplies and medications, etc. The minimum one-second pause keeps our thinking ahead of our doing so that we never act without thinking. If you catch yourself talking to yourself internally (or even out loud), you are doing it right! 

Did you know? 

  1. Self-checking reduces the probability of a skill-based error by a factor of 10 (10x) for a one-second pause. A two to five-second pause can result in a factor of 100 to 1,000 reduction in errors! With those odds, isn’t it worth a few additional seconds to STAR?
  2. The probability of making a skill-based error increases with various factors such as: 
    1. Time pressure 
    2. Interruptions 
    3. Distractions 
    4. Fatigue 
    5. Task complexity 

The importance of self-checking

A radiologist reading a study for a 68 year-old female stops to answer a question for a surgeon. The radiologist unintentionally then opens the Electronic Health Record (EHR) of a 73 year-old male to answer the question. Following the consult, the radiologist proceeds to read his impression of the 68 year-old female into the record of the 73 year-old male. This results in an unnecessary surgical procedure for the 73 year-old male. The male dies eight days later from complications of the procedure. The radiologist could have avoided the error by self-checking following the interruption. 

For more information, please visit the HRO website.