Human Factors and Patient Safety Frank Federico, RPh 8 October 2015 This presenter has nothing to disclose.
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Human Factors and Patient Safety
Frank Federico, RPh
8 October 2015This presenter has nothing to disclose.
Objectives
List three factors that degrade human
performance
Describe three error reduction strategies that
take into consideration human factors principles
Explain how to assess the work environment for
human factors violations
Discussion
What are some key features of a good design?
What is it about a design that makes a piece of equipment or a
process easy or difficult to use?
If not easy to use, how would you modify the design?
Insert some examples of poor or good design….
Human Error4
1. Errors are common
2. The causes of errors are known
3. Many errors are caused by activities that rely on
weak aspects of cognition
4. Systems failures are the “root causes” of most
errors
Lucian Leape, “Error in Medicine” JAMA, 1994
Human Factors
physical demands,
skill demands,
mental workload,
and
other such factors
adequate lighting,
limited noise, or other
distractions
device design, and
team dynamics
Human Factors Engineering: Examines a particular
activity in terms of its component tasks and then
considers each task in terms of:
Human Factors
Human Factors focuses on human beings and
their interaction with each other, products,
equipment, procedures, and the environment
Human Factors leverages what we know about
human behavior, abilities, limitations, and other
characteristics to ensure safer, more reliable
outcomes
6
What is the study of Human Factors?
Human factors”, “human factors engineering” and “ergonomics”
are often used interchangeably
Human factors seeks to
– understand and design systems that take human limitations into account,
– supporting people in areas we know to be challenging and
– capitalizing on human strengths.
Poor design is in the eye of the beholder such as human factors
professionals
8
Our Focus
Understanding the ‘violations’ of human factors
principles that set us up for errors
Determining what to do to address these
violations (building a better bus!)
Think of Systems
People tend to spend time looking at individual
problems without stepping back to see how all
the individual pieces fit together in the larger
scheme of things.
Case
Nurse administers incorrect medication
Root Causes Analysis completed.
Nurse read label incorrectly
Deeper investigation
– Short staffed
– Nurse caring for three very sick and intense patients
– Nurse interrupted repeatedly while on medication rounds
Changes:
– Training and education on 6 rights
– Font on medication label increased.
Did this solve the problem?
Case
Parenteral solutions administered via wrong
route
Changes
– Training and education
– Labels on tubing
– Be more vigilant
Case
Jim Taylor
Immediately scheduled for surgery to repair the femur
Night shift
Focus on his agitation
Change in vital signs
Changes
– Focus on DVT prophylaxis process only
– Retraining of nurses on DVT issues
What did the proposed changes miss?
http://homepage.mac.com/lesposen/iblog/B80495344/C840540124/E1966059962/
Poor Design
Interruptions
Overconfidence
Fatigue
FAILURES
What Impacts Our Performance?
Overestimate abilities
Underestimate limitations
External stimuli– Noise
– Distractions
– Environmental conditions
Internal response to stress– Release of stress hormones
– Anxiety
– Increased heart rate
Error-Producing Conditions
Unfamiliarity with task x17
Shortage of time x11
Poor communication x10
Information overload x 6
Misperception of risk (drift) x 4
Inadequate procedures / workflow x 3
These are compounded by “human factors violations” such as fatigue, stress, work environment (e.g., psychologically unsafe environment), interruptions and distractions, and ambiguity regarding roles and responsibilities.
Handbook of Human Factors and Ergonomics
Gavriel Salvendy
Capacity or Complexity
Human factors engineering research shows that what
is important is not the number of tasks but the nature of
the tasks being
attempted.
An example:
A doctor may be able to tell a student the steps in a
simple operation while he is doing one but if it was a
complicated case he may not be able to do that because
she/he has to concentrate.
19
Human Factors Violations:
Drivers of Human ErrorFatigue
Lack of sleep
Illness
Drugs or alcohol
Boredom, frustration
Cognitive shortcuts
Fear
Stress
Shift work
Reliance on memory
Reliance on vigilance
Interruptions & distractions
Noise
Heat
Clutter
Motion
Lighting
Too many handoffs
Unnatural workflow
Procedures or devices designed in an accident prone fashion
Fatigue
Two factors with the most impact are fatigue and stress.
Prolonged work has been shown to produce the same
deterioration in performance as a person with a blood alcohol
level of 0.05 mmol/l, which would make it illegal to drive a car in
many countries
Shift Work
Truck drivers are typically allowed to work no more than
10 hours at a time and no more than 60 hours in one
week.
Airline pilots and air traffic controllers work regulated
hours and some data suggest waning performance as
work-hours increase.
No studies that evaluated direction of shift work rotation
among medical personnel
Sleep deprivation and disturbances of circadian rhythm
lead to fatigue, decreased alertness, and poor
performance on standardized testing.
No testing in healthcare workers
Shift Work
The direction of shift rotation may impact worker
fatigue.
A forward rotation of shift work (morning shifts
followed by evening shifts followed by night
shifts) may lead to less fatigue on the job than
backward rotation (day shift to night shift to
evening shift).
Stress
While high stress is something that everyone can
relate to, it is important to recognize that low
levels of stress are also counterproductive, as
this can lead to boredom and failure to attend to
a task with appropriate vigilance.
Reliance on Memory
Working memory is limited, and when attention is drawn
elsewhere, it can be especially vulnerable
Short Term Memory
Do you easily remember things like medical
record numbers or verbal orders?
What do you think would happen if you were
interrupted or distracted while remembering
these things?
Why do you think you forget this information?
Long Term Memory
Long term memory is where people store facts
about the world and how to do things.
Mental models are used to store this information
and it can be retrieved either by recalling it or
recognizing it
– A phone number
– A song
– Directions
– Recipe
Attention
Attention describes the ability to concentrate on
someone or something.
Attention is limited and so those stimuli that are
ignored will never get processed by the brain.
Instead what is ignored will go unnoticed and will
not be remembered.
Attention
Multitasking
Interruptions
Adverse events can occur when the available
cognitive resources such as memory are
insufficient for the task at hand.
IT– Current generation clinical ITs are designed with the implicit
assumption that their users are carrying out a single task and that
their attention is devoted entirely to the interaction with the
technology.
Error Reduction Overview: Hierarchy of
Controls
32
Standardization & Simplification
Policies,
Training,
Inspection
Minimize consequences
of errors
Make it easy to do
the right thing
Make it hard to do the wrong thing
Eliminate the opportunity for error
Human
Factors
Mitigate
Facilitate
Eliminate
Make errors visible
Doug Bonacum
Specific Error Reduction Strategies
Use visual controls
Avoid reliance on memory
Simplify and Standardize
Use constraints/forcing functions
Use protocols and checklists
Improve access to information
Reduce handoffs
Decrease look-alike / sound-alikes
Automate carefully
Reduce interruptions and distractions
Take advantage of habits and patterns
Promote effective team functioning
33
Usability Testing
Usability testing is also essential for identifying
workarounds—the consistent bypassing of
policies or safety procedures by frontline
workers.
Workarounds frequently arise because of flawed
or poorly designed systems that actually increase
the time necessary for workers to complete a
task. As a result, frontline personnel work around
the system in order to get work done efficiently.
Ease of Use
The design of a process or device should
provide visual clues as to how the process
should flow or the piece of equipment is to
be used
The environment should give clues about
how to interact with the process or
equipment.
1. Norman, The Design of Everyday Things
Forcing functions
An aspect of a design that prevents an
unintended or undesirable action from being
performed or allows its performance only if
another specific action is performed first.
For example, automobiles are now designed so
that the driver cannot shift into reverse without
first putting his or her foot on the brake pedal.
Anesthesia
Mix up of gases
Changed connectors for different gases
Mix up of gases no longer a problem.
Tubing Connections
Figure 1. Tube delivering
oxygen fell off nebulizerFigure 2. The oxygen tubing was connected
to a Baxter Clearlink needleless port.
Affordances
Perceived and actual properties of technologies
that determine how they might be used.
For example, if someone sees a button, he/she
assumes it must be pressed rather than trying to
slide or turn a button to get it to work.
Standardization
An axiom of human factors engineering is that
equipment and processes should be
standardized whenever possible, in order to
increase reliability, improve information flow, and
minimize cross-training needs.
Standardized equipment across clinical settings
as in the defibrillator
Standardized processes such as the use of
checklists
Environmental Cues
Enhance an individual’s capacity to recover from
interruption.
When calculating a drug dose on paper,– The paper acts as a cue to help a clinician re-engage with the task after
an interruption,
– Recalling their position in the task sequence and recording intermediate
calculations and initial data.
The Case of Nifedipine Gel
Simplicity of Design
Use Visual Controls 49
Stove A
Stove B
Which dial turns on the burner?
50
51
52
Computerized drug-drug interaction
checking
– Drug information databases
– Customized drug rules
Preprinted orders
– Chemotherapy order form
– Pain management order forms
Avoid Reliance on Memory
53
Formulary restrictions
– Remove items
– Eliminate therapeutic duplications
– Limit availability
Heparin weight based protocol
– Simplifies ordering process
– Provides comprehensive orders
Simplify
54
Why Simplify Workflow?
STEP 1 STEP 2 STEP 3 STEP 4
90% 90% 90% 90%
First step =
90%
Process reliability = 90% * 90% * 90% * 90% = 66%
55
Who, what, with what, when, where, how
– Example from Reliability Session
– “Win / Win” - Less work, better care
Standard solutions
– Ease of ordering
– Ease of preparation
– Ease of administration
Standardize
56
Checklists
– Reminders of every step in the process
– NOT rigid molds for non-thinking behavior
– Pilot checklists: includes method to
designate where stopped if interrupted
– Anesthesia Machine Checklist
Use Protocols and Checklists
57
Include “Indication” with orders/prescriptions
Drug information sources
– Determine ease of use
Location of medication list/problem list
Improve Access to Information
58
Pharmacists on rounds
– MD and Pharmacist interact directly
– Increases likelihood of the correct order
– Reduces delays caused by problematic orders
Communicating critical test results
– Communicate directly with ordering provider
Reduce Handovers
59
Strategy: Avoid Look-alike/Sound-alike
Drug Names
Display lists of easily confused drug namesHow effective?
Strongly encourage – Writing prescriptions more clearly
– Printing in block letters rather than writing in
cursive
– Avoiding the use of abbreviations
– Indicating the reason for the drug
60
Errors multiply if input is incorrect
Automated dispensing machines
Computerized physician order entry
Automate Carefully
61
Reduce Interruptions and Distractions
62
Reduce Interruptions and Distractions
Ask: “What are critical alarms?”
Are personal phones best way to help nurses?
Have you thought about patient comfort?
How many alerts pop-up in a computer system
during order entry?
Is there a ‘quiet zone’ for medication
administration? (e.g. Green Vest at KP)
63
Take Advantage of Habits and Patterns
Identifying high risk patients
in the office setting– Engage patients while waiting
Hand hygiene– Must become part of behaviors
– Habit
64
Habits and Patterns (Continued)
Patient medication
list
– Sleeve to hold
insurance
card and
medication list
Hand Hygiene
Using a nudge instead of a ruleNudge theory is mainly concerned with the design of
choices, which influences the decisions we make. Nudge
theory proposes that the designing of choices should be
based on how people actually think and decide
(instinctively and rather irrationally), rather than how
leaders and authorities traditionally (and typically
incorrectly) believe people think and decide (logically and
rationally).
65
Promote Effective Team Functioning
66
Listening Exercise
67
Please decide if the following statements are true, false
or ? (unable to determine with the information given)
A man appeared after the owner had True /False /?
turned off his store lights
The robber was a man. True /False/?
The robber did not demand money. True/False/?
The owner opened the cash register. True /False/?
After the man who demanded the money scooped up the contents of
the cash register, he ran away. True /False/?
While the cash register contained money, the story does not state
how much. True /False/?
Steve Kerr, GE
68
Technology
69
What are the technologies employed at your
hospital?
Computerized
prescriber order entry
Electronic medication
administration records
SMART Pumps
Robotic dispensing
Ventilators
Defibrillators
Anesthesia machine
Bar code technology
Radio Frequency
Devices
Automated dispensing
machines
Diagnostic equipment
And…..
Global Problems with Technology
Magical thinking – It starts something like
this: Let’s have technology do that.
What does this type of thinking miss?
Can you think of examples of magical
thinking?
The Problem
Sometimes it is in the design
Sometimes it is in the interface with users
Sometimes it is in the implementation
Sometimes it is in how applied
Sometimes it is in our expectations
Sometimes it is a mismatches between system
workflow and clinical workflow
Implementation
Failure to understand the adaptive nature of
implementation is no doubt one of the main reasons
health IT systems flounder post-installation.
The implementation work required when new information
systems are installed also provides an opportunity for
redesign and optimization of existing clinical processes
Clinical processes, work practices and their supporting
technologies probably need to be designed with a ‘use-
by’ date.
Automation Bias
When humans delegate tasks to a computer
system they may also shed task responsibility
Computer users may then take themselves out of
the decision loop
Automation Bias
Automation bias or automation-induced complacency is a
very specific bias associated with computerized decision
support and monitoring technologies
A user can make either errors of omission (they miss
events because the system did not prompt them to take
notice) or
A user can make errors of commission (they did what the
decision system told them to do, even when it contradicts
their training and available data)
Socio-technical Aspect
The socio-technical nature of IT means that the
technology and the context within which it is used
cannot be separated
The Impact of the Automated Automobile
The Monk and the Help Desk
“The problem with making the transition from the
paper world to the electronic world is that in the
paper world a lot of things happen by
convention & understanding…implementing the
electronic tools to make that happen is a bigger
deal than I think anybody expects.”
Chair, Medical Informatics Committee
Evanston Northwestern Healthcare
Tendency to underestimate the
complexity embedded in paper
Alarm-related Deaths
According to The Joint Commission, there were 80
alarm-related deaths in the U.S. between January
2009 and June 2012.
http://psqh.com/alarm-fatigue-hazards-the-sirens-are-calling
MGH Death Spurs Review of Patient
Monitors
“A Massachusetts General Hospital patient died
last month after the alarm on a heart monitor was
inadvertently left off, delaying the response of
nurses and doctors to the patient’s medical
crisis.”
“Hospitals don’t turn up the volume, lower the
noise.”
Noise in health care facilities has increased by multiples in past decades, and it has a negative effect on health in several ways, not only through missed alarms.
These include increased stress
and disrupted sleep for patients,
lost privacy, communication errors,
and clinician burn-out.http://www.boston.com/bostonglobe/editorial_opinion/letters/articles/2010/02/28/hospitals_dont
_turn_up_the_volume_lower_the_noise/
SoundEar
In order to achieve effective alarm
management
Must deal with culture
Must use a multidisciplinary approach
Develop appropriate processes
One size does not fit all
89
What Can You Do?
Include human factors analysis in incident investigations
Conduct human factors review of organization– Are processes standardized?
– Is there ready access to information?
– Are redundancies and reminders in place?
Conduct a human factors task analysis– How many interruptions are there during the work shift?
– How complex are the tasks or
instructions?
Usability testing
Human factors engineers test new systems and equipment under
real-world conditions as much as possible, in order to identify
unintended consequences of new technology.
Example of the clinical applicability of usability testing involves
electronic medical records and computerized provider order entry
(CPOE). A seminal study found increased mortality in a pediatric
intensive care unit after implementation of a commercial CPOE
system, attributable in part to an unnecessarily cumbersome
order entry process that reduced clinicians' availability at the
bedside
91
What Can You Do?
Conduct human factors audits
– Noise levels; distractions; design of workspace; label
format; work hours review; shift reviews
Train staff: Self-awareness of human factors issues
– Staff in position to monitor ongoing situations
– Information overload
– Back to back shifts or only short breaks between shifts
Role of Leaders
Proper review of new technology for usability
Encourage reporting of technology-related errors
and defects
Include examination of human factors and
technology design after an adverse event
Obtain feedback from users
Look for workarounds that may indicate
technology or processes not easy to use
Recommendation
You can play an integral role in ensuring that the
organization has a plan to evaluate where to
dedicate resources
– Done by including technology as part of strategy
– Important because technology is part of structure
– Technology can introduce a whole new set of problems
– Think of unintended consequences
94
VA National Patient Safety Center
http://www.patientsafety.va.gov/professionals/onthejob/cognitive.asp
“We can’t change the human
condition, but we can change
the conditions under which
humans work.”
James Reason
95
Take a moment to reflect
on your own work.
What will you incorporate from
this session into your plans?
Related Documents
