Human Factors Engineering in Patient Safety

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Human Factors Engineering in Patient Safety
Quality Management

• Based on the work of Health Insight, Utah QIO
• Patricia L. Baker, RN, MS
• 2009

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Objectives

• Examine Human Factors in errors
• Discuss the The Big 3 categories of performance
  gaps
• List the 3 performance levels
• Review strategies to manage errors

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Human Factors

• The science of designing tools, tasks,
  information, and work systems to be compatible
  with the abilities of human users this includes
  both physical and cognitive abilities.

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Institute of Medicine Reports

• Human error is a risk factor for adverse events
• Scientific approach is essential
• Health care implications
• Quality management
• Improving safety
• Developing an effective safety culture
• To Err is Human
• Crossing the Quality Chasm

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Patient Harm - the GAP betweenwhat is and what
could be
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Error

• those occasions in which a planned sequence of
  mental or physical activities fails to achieve
  its intended outcome and the failure cant be
  attributed to the intervention of some chance
  agency.
• Execution (slips, lapses)
• Planning (mistakes).
• Reason, 1990

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Historical View of Human Error

• Human errors cause accidents
• Failures are surprises
• Complex systems would be fine if it werent for
  some unreliable people

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Human Factor View of Errors

• Human error is not the cause of accidents, it is
  a symptom of deeper issues
• Human error is not random
• Human errors should not be the conclusion, but
  the beginning of deeper investigations

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Confounding Factors in Errors

• Design Issues
• Procedures
• Management role

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Public Perception of Error

• -Attribution error or blame
• -Surprise error

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Punishing Errors in Health Care

• Loss of license,
• Suspension,
• Disciplinary actions,
• Why doesnt this work?
• What side-effects does it have?

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Learning from Error

• Recognize that we are all subject to the
  fundamental attribution error
• Recognize that we may be subject to a fundamental
  surprise error
• Recognize the dangerous off-ramps designed into
  the system
• See errors as indications of system problems
• Move beyond common sense design

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The Big 3 Performance Gaps

• Execution error plan not carried out correctly
• Planning error the plan itself was inadequate to
  achieve the desired outcome
• Violation deliberate departure from safe
  practice

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Execution Error

• Distracted or interrupted
• Steps are too similar
• I forgot
• It slipped my mind

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Planning Error

• Plan should include
• Goal or desired outcome
• Necessary steps
• Steps are clearly understood
• Time
• Common mental model
• Constructive feedback

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Violations

• Intentional deviations from safe operating
  procedures, standards, or rules.
• Choice

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Violation Producing Conditions
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Performance Levels Cognition
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Performance Level Error Types
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Performance Levels Likelihood of Error
exposure
likelihood of error
Skill- based
Rules- based
Knowledge- based
Performance level
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Managing Errors HFE Diagnosis

• Task complexity, information available, memory
  demands
• Compatibility with operators training or
  experience
• Time constraints/time pressures
• Work context, competing goals, mindset
• Coordination and teamwork
• Organizational, professional and workgroup norms

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Framework 1 Someone, Doing Something, Somewhere

• Someone
• Training/knowledge/skills
• Physical capabilities, fatigue,
• Doing something
• Task characteristics
• Operator goals
• Somewhere
• Work environment and context
• Mindset

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Framework 2 Demands on Operator

• Errors identify exceptional demands on
• Perception
• Attention
• Working memory
• Long term memory
• Decision/response selection
• Response execution
• Delayed performance feedback
• Violations a potential contributor?
• Goal conflicts
• Incentives
• Inconvenience

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Framework 3 Performance-Shaping Factors

• Communication
• Coordination of effort, teamwork
• Time pressure and constraints
• Task complexity, degree of proceduralization
• Organizational, professional, or workgroup norms
• Data overload
• Compatibility with training and experience
• Information management

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Human Factors Engineering in Design

• Performance is a product of design
• Check user environment noise, light, movement,
  etc.
• Check user characteristics knowledge, skill,
  limitations, etc.
• Check device define operating procedure,
  simplify designs, conduct testing, etc

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Strategies for Managing Errors

• Strategies that do work
• Prompts
• Reminders
• Memory aids
• Training or education
• Creating a new process
• Strategies that may not work
• Punishment
• Rewards
• Training/education of skilled workers

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Developing an Effective Safety Culture

• A safety culture depends on
• Meaning assigned to errors and accidents
• Staff motivation, competence, caring, commitment
• Viewing errors as learning opportunities
• Avoiding punishment for true errors
• Blame-free system for reporting near misses

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HF Benefits Limitations

• Human Factor Benefits
• Avoids blame
• Examines errors as systems problems
• Learn from near misses and mistakes
• Provides management strategies
• Makes correct path more visible
• Human Factor Limitations
• Requires a new way of thinking about errors
• Difficult to establish a blame-free reporting
  system

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References

• Reason J. Human Error. New York Cambridge
  University Press, 1990.
• Rasmussen J, Pejtersen AM, Goodstein LP.
  Cognitive Systems Engineering. New York John
  Wiley Sons, Inc., 1994.
• Kaye R, Crowley J. Medical Device Use-Safety
  Incorporating Human Factors Engineering into Risk
  Management, US Department of Health and Human
  Services Center for Devise and Radiologic
  Health, 2000.
• Institute of Medicine, Crossing the Quality
  Chasm A new health system for the 21st century,
  National Academies Press, Washington DC. 2001
• Institute of Medicine, To Err is Human Building
  a Safer Health System, National Academies Press,
  Washington DC. 2000