Applying Human Factors to Improve Patient Safety Matt Scanlon, MD, CPPS Professor of Pediatrics-Critical Care Medical College of Wisconsin Founding and Executive Member Paediatric International Patient Safety and Quality Community [email protected]
Sep 12, 2015
Applying Human Factors to Improve Patient Safety
Matt Scanlon, MD, CPPS Professor of Pediatrics-Critical Care
Medical College of Wisconsin
Founding and Executive Member
Paediatric International Patient Safety and Quality Community
qu ves
The Human Factor X
Human Factors Engineering
(Ergonomics)
Somebody made a mistake
5
productividad
calidad eficiencia
seguridad
Comportimiento humano
Goals of Human Factors
ORGANIZATION
ENVIRONMENT TOOL &
TECHNOLOGY
TASKS
ENVIRONMENT
PEOPLE
Safety and
Harm
Substitution Test for systems problems
Work Systems Model
Carayon 1989, 2000, 2000
Work System Process Outcomes
Carayon 2006
8
Cuando usted sabe cuntos resultados estn
fuera de rango , que levante la mano
9
intntalo de nuevo
10
11
14.5 mg of morphine sulfate in 2 mg/2mL syringes
106,065 medication orders
99,340 alerts
Bair Hugger
What about Lean/Six Sigma?
Patient Safety Safety Science
The Perspective of Safety-I
I attribute it to human error. But then I attribute everything to human error
assumptions in safety-I
31
32 32
view from safety-II
assumptions in safety-II
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empirical support
direct observations of CV surgery
surgeons w/ best results
had just as many untoward
events as those w/ worst
but they had better means of detection greater repertoire of responses
de Leval 2000
35
but they had better means of detection greater repertoire of
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Learning in Safety I v II N
um
ber
of
Ou
tco
mes
Range of OutcomesPoor Excellent
What is the relationship between the activities of Safety and Quality?
Safety I and Quality: Reduce (non-value added?)
variation
Safety II: Promote adaptability
(resilience)
Both necessary; Systems and context determine how much of either
Resilient Systems
must respond in an appropriate manner in real time (including when coping with the unexpected)
Resilient Systems
must have adequate surveillance capability
Resilient Systems
must be forward looking, anticipating what can happen and preparing responses
Resilient Systems
must learn from experiences
Resilient Systems
Have the ability to make sacrificing decisions (such as accepting a short term loss in exchange long term success,
or cutting ones losses)
ORGANIZATION
ENVIRONMENT TOOL &
TECHNOLOGY
TASKS
ENVIRONMENT
PEOPLE
Safety and
Harm
Carayon 1989, 2000, 2000