Post on 07-May-2015
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Human Factors: Human Error?
To Err is Human – Planning for the human element in healthcare
Patient Safety Team
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The amazing colour changing card trick
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If someone makes a mistake is it due to ………………….
• Human Error?
• Human Unreliability?
• Human Performance Problem?
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Human Error
“We cannot change the human condition but we can change the conditions under which humans work.”(Reason, 2000)
“Blaming individuals is emotionally more satisfying than targeting institutions.” (Reason, 2000)
“Human error is the failure of desired actions to achieve their desired ends.” (Reason, 1990)
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Planning for the human element in healthcare
• Why were medicines given to the wrong patient?• Why was the needle recapped before disposal?• Why lift manually when a ceiling lift was available?• Why weren’t gloves and a mask worn?• Why was the patient agitation/pain not noticed?
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What is human error?
“Human error is a failure of planned actions to achieve their desired ends” (Reason, 1990)
PLAN
PLANNINGMISTAKES
EXECUTIONERRORS
ACTIONS OUTCOME
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What is human error?
It is an imbalance between
• what the situation requires • what the person intends• what he/she does
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Human error happens when…
• Plan to the right thing but with the wrong outcome
• Do the wrong thing for the situation
• Fail to do anything when action is required
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Why do errors happen?
• Simply put errors happen when multiple factors come together to allow them to happen
• Human error = System error
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Human Factors Issues • Errors are the result of a system as a whole
• Context is everything
• No longer about – Naming– Blaming– Shaming– Retraining
• Isolate errors from context and human factors has little or no remedial value
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Why is this important?
Example: Medication Error
Primary Consequence: Patient’s Health
Other Consequences: • Increased workload for patient care• Stress, anxiety, guilt for health care professionals• Stress for supervisors and managers• Financial consequence for the organisation
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The system model (Reason 2006)
• Fallibility is part of the human condition• Adverse events are the product of latent
pathogens within the system• Sharp enders are more likely to be the
inheritors than the instigators• Remedial effort is directed at improving
differences and removing error traps• Need safety culture to motivate personal
responsibility to prevent errors
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Reason’s Accident Causation Model
• Latent Conditions
• Error producing conditions
• Active failure
• Defences
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The Swiss cheese model of how defences, barriers, and safeguards may be penetrated by an accident trajectory.
Reason J BMJ 2000;320:768-770
©2000 by British Medical Journal Publishing Group
Mitigation
Recognition
Prevention
Policy
LeadershipRapid
Response
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Active Failure
• Active failure– Occur at the level of the front line operator– Slips, lapses and mistakes– Violations (deliberately ignoring rules)
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Error Producing Conditions
• Error producing conditions– Environmental– Team– Individual– Task factors which effect performance
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Personal & environmental factors
• Personal Factors• Fatigue• Lack of sleep• Illness• Irregular work patterns• Drugs or alcohol• Boredom• Frustration• Fear • Shift work• Reliance on memory• Reliance on vigilance
• Environmental Factors• Distractions
– Noise– Heat– Clutter– Motion– Lighting
• Too many handovers– Unnatural workflow
• Poorly designed procedures or devices
• Inadequate training and skills
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A smoke filled room
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Latent Conditions
• Tend to be removed from the direct control of the operator
• Poor design • Incorrect installation• Faulty maintenance• Bad management decisions• Poorly structured organisations
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Defences
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Human Factors Gear Box
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Skills Rules Knowledge Framework (Rasmussen, 1983)
Automatic
Conscious
Rule Based
Knowledge Based
Skill Based
Unskilled or occasional userNovel environment
Pre-packaged behaviour e.g. if the symptom is X then the problem is Y, OR if the problem is Y do Z
Automated and requires little conscious attention
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Conscious
Control Mode
AutomaticSituation
Routine
Novel Problem
Skill basedBehaviour
Rule basedBehaviour
Knowledgebased
Behaviour
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Slips and Mistakes
• Slips– Intention is correct but a failure occruing when
carrying out the activity required
• Mistake– Incorrect intention which leads to an incorrect
action sequence. These usually occur due to lack of knowledge.
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Human Error TaxonomyHuman Failure
Violations
EXCEPTIONAL:Boundaries are changed inOrder to full fill rush order
Routine:Operator does not follow
Because out of date
Errors
MISTAKESSLIPS
KNOWLEDGE BASEDA LACK OF EXPERTISE
RULE BASEDA failure of expertise e.g.
Wrong diagnosis
SKILL BASEDMisapplied competence e.g.
Operator fails to close one valve Due to confusion with another
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Managing Human Error in Healthcare
1. Prevent Error2. Recognise Error3. Mitigate Error
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Use Human Factors Knowledge to design systems
• Standardise the work environment• Select equipment with safety features• Provide backup for critical personnel and
equipment• Provide clear supervision and direction
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Example
The pharmacy porter whose job it is to deliver medicines to the wards injures their shoulder and is unable to work
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Simple Analysis
Pushing the trolley caused the injury
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Human Factors Analysis
• The porter had had a sore shoulder for many weeks but had failed to report his symptoms because they could still work (error in early reporting and porter training)
• The trolley was old and didn’t run in a straight line because the wheels were wonky. (error in policy and maintenance)
• The trolley was too tall to see over when full; therefore full trolleys were pulled instead of pushed. (error in purchasing and job design)
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Exercise
• Discuss the last error that you were involved in / analysed and consider this from a human factors perspective.
• How does the theory apply to this?• Knowledge• Skill• Behavioural errors
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Human Error Type
Typical Forms Common Prevention Strategies
Slip / Lapse • Double capture• Omission• Interference• Perpetual
Confusion
• Minimising Interruptions• Forcing Functions• Colour coding, highlighting
differences• Checklists, memory aids
Rule Based Mistake
• Strong but wrong• Exception to rule• Cognitive Overload
• Minimise / highlight exceptions
• Provide feedback• Manage workload
Knowledge based mistake
• Confirmation bias• Out of sight, out of
mind
• Decision support• Team work
Summary
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Exercise• Look at your process and consider how you
will include Human Factors in your design.
• Think about how you will observe your process through fresh eyes.
Insert date/time
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How it fits
• Now is the time to use your safety improvement knowledge:
• Human Factors• Model for Improvement• PDSA and small tests of change• Metrics and measurement for Improvement• Engagement• Spread and adoption• Sustainability