High Reliability / Human Factors - 1000 Lives Plus...High Reliability / Human Factors Chris Hancock & Mike Fealey: Programme Managers, 1000 Lives Plus Acknowledgement •Kind thanks

High Reliability / Human

Factors

Chris Hancock & Mike Fealey: Programme Managers, 1000 Lives

Plus

Acknowledgement

• Kind thanks to Atrainability for some of

the info and slides contained in this

presentation

Working Together

Rollercoaster

Mortality

• 1 in 1.5 billion chance of being fatally

injured at an amusement park

• Injury rates for golf and deckchairs are

higher

– US Consumer Product Safety Commission

(2007)

Hospital Mortality and

Harm• There is a one in 300

chance of accidental death

through errors in care. (Institute of Medicine, 2000)

• More than one in ten

people admitted to hospital

are harmed unintentionally

by its care. (Vincent et al. 2001)

• 11859 adult

preventable deaths

in hospitals in

England• Horgan et al 2012

Patient Safety

3,283 patients dead through preventable error, another 7,000 suffer severe harm

Equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year……

…..in the UK!

Shall We Save 100 Lives

www.1000livesplus.wales.nhs.uk

Mid Staffs Questions ...

• What are the warning signs that a hospital (or

any other part of the NHS) is in trouble?

• Why did so many senior staff in giving evidence

express their horror that they had not known

about the poor care on many of the wards?

• Is Stafford a classic case of organisational

blindness?

• The question I want you to keep asking

yourselves as we relay the story is, ‘Could it

happen on my patch? Could it happen in my

hospital and how would I know?’

– Prof Edwards 2012

Hands up

Who comes to

work to harm

people?

So who’s fault is it?

Insert name of presentation on Master Slide

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• Now take a minute per question to

come to agreement on each table

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Pattern recognition

• Aoccdrnig to a rscheearch at Cmabrigde

Uinervtisy, it deosn‘t mttaer in waht oredr the

ltteers in a wrod are, the olny iprmoatnt tihng

is taht the frist and lsat ltteer be at the rghit

pclae. The rset can be a toatl mses and you

can sitll raed it wouthit porbelm. Tihs is

bcuseae the huamn mnid deos not raed

ervey lteter by istlef, but the wrod as a wlohe.

The Gap Between

Perception and

Practice

What We Think We Do

Vs.

What We Actually Do

Mitchell Levy,

Director, Surviving Sepsis

Campaign

• Human error is a natural consequence

of being human

Power of memory

Working Together

Working Together

Who are the best multi-taskers?

Working Together

Working Together

Working Together

Human cognition

Working Together

..and the result is..

Working Together

Stress – how full is your bucket?

Working Together

TOP TIPS

Beware

• Hungry

• Anxious / angry

• Late

• Tired

Working Together

It is important not to blame individuals for what went wrong but to understand why, what they did at the time, made sense to

them.

‘Just Culture’ - Dekker - 2007

High risk situations for

error

• Interruptions and distractions

• Tasks required out of normal sequence

• Unanticipated new tasks

• Multitasking.

Why Errors HappenFactors making error/violation more likely

• Fatigue

• Stress

• Illness

• Overload

• Inexperience

• Complacency.

Problem types

• Care Delivery Problem

– Direct provision of care, problem arises in

the process of care usually actions or

omissions by staff- Active Failures

• Service delivery problem

– Absence of guidance to enable actions to

take place- Latent Failures

The First Law of

Healthcare Improvement

“It is not bad people but bad systems that harm and kill our patients”

Source: Don Berwick, IHI (Boston)

Reliability

• Achieving reliability means doing the

right thing for every patient every time

Human Factors

• Making it easier to do the right thing

Human Factors

Approaches

• Make communications visible

• Decrease reliance on vigilance – error

proof

• Avoid reliance on memory - use prompts

• Simplify processes – SOP

• Use checklists

• Standardise

Make communications highly

visible

Decrease the reliance

on vigilance – error

proofing

Avoid reliance on

memory – use prompts

Review and simplify

processes – standard

operating procedures

Routinely use

checklists

Standardise common

processes and procedures

NEWS card & iPhone App available

Summary

• It is not bad people but bad systems that cause harm and death

in healthcare – human error is inevitable

• Most error in healthcare is due to system rather than individual

failure

• Every system is perfectly designed to achieve the results that it

gets – use human factors thinking

• You cannot achieve reliable outcomes without first achieving

reliable processes

• You have 1 job with 2 roles

– Doing your job

– Improving your job