Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh...
-
Upload
eli-governor -
Category
Documents
-
view
221 -
download
2
Transcript of Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh...
![Page 1: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/1.jpg)
Human Factors in Healthcare
Dr Nikki Maran
Consultant Anaesthetist, Royal Infirmary of Edinburgh
Director, Scottish Clinical Simulation Centre,
Forth Valley Royal Hospital, Larbert
![Page 2: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/2.jpg)
![Page 3: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/3.jpg)
Human Factors...
• ‘...refers to environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work (in a way that can affect health and safety.)’
• Health and Safety Executive (1999)• Reducing Error and Influencing Behaviour
![Page 4: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/4.jpg)
Basic Tenets of Human Factors
• Everyone makes mistakes
• Errors are often beyond our conscious control
Systems that depend on perfect human performance are fatally flawed.
![Page 5: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/5.jpg)
The Human Factors Approach
Helps us understand why things don’t work right ….and find solutions!
![Page 6: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/6.jpg)
The Human Factors Approach
Helps us understand why things don’t work right ….and find solutions!
• The task / technology (hardware / software)• The individual (liveware)• The organisation (environment)
![Page 7: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/7.jpg)
The task / technology
![Page 8: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/8.jpg)
![Page 9: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/9.jpg)
![Page 10: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/10.jpg)
![Page 11: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/11.jpg)
Human Factors Solutions
• Ergonomics
• Improved Design
• Improved labelling / packaging
![Page 12: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/12.jpg)
The individual
![Page 13: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/13.jpg)
Why did Elaine die?
• Failure to intubate• Failure to oxygenate
![Page 14: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/14.jpg)
Human Factors in Safety
AccidentCausation
Technical Factors
Human Factors
Organisational / SafetyCulture
OperatorBehaviour= +
(30-20%)
(70-80%)
![Page 15: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/15.jpg)
Human Factors in Safety
AccidentCausation
Technical Factors
Human Factors
Organisational / SafetyCulture
OperatorBehaviour= +
(30-20%)
(70-80%)
![Page 16: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/16.jpg)
Why did Elaine die?
• Failure to intubate• Failure to oxygenate
• Failure of leadership• Breakdown in decision making• Communication dried up• Lack of assertiveness• Loss of awareness
![Page 17: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/17.jpg)
Why did Elaine die?
• Failure to intubate• Failure to oxygenate
• Failure of leadership• Breakdown in decision making• Communication dried up• Lack of assertiveness• Loss of awareness
![Page 18: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/18.jpg)
Non-technical skills
Avoid problems
Identify & treatincidents
Manage emergencies
![Page 19: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/19.jpg)
Health Committee patient safety report for NHS England (July, 2009)
“The NHS lags unacceptably behind other safety-critical industries, suchas aviation, in recognising the importance of effective team working and other non-technical skills.” (p5)
“There are serious deficiencies in the undergraduate medical curriculum .. which are detrimental to patient safety, in respect of training in ……non-technical skills....” (p6)
![Page 20: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/20.jpg)
Human Factors Solutions
Identifying NTS in healthcare
![Page 21: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/21.jpg)
Situation Awareness
Decision Making
Task Management
Team Working
Gathering Information
Recognising & Understanding
Anticipating
Anaesthetists’ Non-Technical Skills
Skill Categories
Skill Elements
Behavioural Markers
Good: keeps ahead of the situation by giving fluids / drugs Poor: is caught unaware by surgical actions
![Page 22: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/22.jpg)
Human Factors Solutions
“The NHS must be able to provide the sort of simulation training that would make a difference to patients like Elaine Bromiley.”
CMO Annual Report 2008
![Page 23: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/23.jpg)
The organisation
![Page 24: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/24.jpg)
Systems Error
Everyday Examples
– Can put petrol in diesel tank
– Cars lurch forward when started in gear
Healthcare Examples– Patients admitted to wrong
wards due to bed shortages
– Legibility of handwritten orders (prescriptions)
• Allowing 100 mg to be administered if 10 mg was ordered
![Page 25: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/25.jpg)
• Forcing functions • Redundancy• Simplification• Standardization • Automation and computerisation• Improve hand-overs• Improve access to information• Decrease reliance on memory
Human Factors Solutions
![Page 26: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/26.jpg)
Effective Systems
From Reason
Error stopped,
no Accident occurs.
Develop systems and processes to prevent errors/accidents from happening and that
can manage them when/if they occur.
![Page 27: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/27.jpg)
Moving Systems Towards Safety
• An unreported error/vulnerability cannot be investigated
If we don’t know about it, we can’t investigate it and we can’t fix it.
![Page 28: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/28.jpg)
Barriers to Reporting
• Punitive culture
• Don’t know what to report
• Time
• Cumbersome reporting systems• Poor feed-back of reported events/actions
• Belief that “reporting doesn’t make any difference”
• Belief that “work-arounds” are the normal way of doing business
![Page 29: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/29.jpg)
Learning from adverse events
• Identifying ‘near misses’– An error that occurs somewhere in the
process, but does not reach the patient– An error that has not turned into an
accident
• Could the recurrence of this event put another patient at risk in the future?
![Page 30: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/30.jpg)
Incidents have been reported of air sucked in to the line from Y-ports of extension sets used with syringe pumps. Risk: air bubbles being pumped into the patient.The incidents have occurred with Wescott extension sets fitted with Y-ports.They have arisen since Wescott changed from a non-vented to a vented cap on the Y-port.
Potential problem recognised March 2010
Vented cap on Y-port.Air bubble in line
![Page 31: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/31.jpg)
Incidents have been reported of air sucked in to the line from Y-ports of extension sets used with syringe pumps. Risk: air bubbles being pumped into the patient.The incidents have occurred with Wescott extension sets fitted with Y-ports.They have arisen since Wescott changed from a non-vented to a vented cap on the Y-port.
Potential problem recognised March 2010
July 2010PCA attached to central venous catheterPatient on CVVHAir entrained as aboveMassive air embolus results in dense hemiplegia
Vented cap on Y-port.Air bubble in line
![Page 32: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/32.jpg)
Learning from adverse events
• Identifying ‘near misses’– An error that occurs somewhere in the
process, but does not reach the patient– An error that has not turned into an
accident
• Could the recurrence of this event put another patient at risk in the future?
• If so, DO SOMETHING TO RECTIFY
![Page 33: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/33.jpg)
Changing the Culture
• Eliminate “shame and blame” mentality from healthcare
• Accept that our clinical staff will make errors and build systems to support their work
• Foster a culture of safety where people can speak up
• Organizational learning from errors and near-misses
![Page 34: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/34.jpg)
The Human Factors Approach
Helps us understand why things don’t work right ….and find solutions!
• The task / technology (hardware / software)• The individual (liveware)• The organisation (environment)
![Page 35: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/35.jpg)
![Page 36: Human Factors in Healthcare Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley.](https://reader035.fdocuments.in/reader035/viewer/2022062404/551ba3fe550346167e8b5bc2/html5/thumbnails/36.jpg)
www.chfg.org
www.institute.nhs.uk
www.iprc.abdn.ac.uk/ants
www.scsc.scot.nhs.uk