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Human Factors: The Science of ReliabilityMSHRM – February 2015

Anne Huben-Kearney, RN, BSN, MPA, CPHQ, CPHRMAssistant Vice President, Healthcare Risk Management

AWAC Services, a member company of Allied World

Kathleen Murray, RN, CPHRM, CPPS, FASHRMAssistant Vice President, Healthcare Risk Management

AWAC Services, a member company of Allied World

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Slide 2 Disclaimer

This presentation is not intended to be and should not be used as a substitute for legal or

medical advice. Rather it is intended to provide general risk management information only. Legal or medical advice should be obtained

from qualified counsel to address specific facts and circumstances and to ensure compliance

with applicable laws and standards.

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Slide 3 Human Factors

Learning Objectives:

Describe the basic concepts of the science of human factors.

Identify the causes of error in your everyday life.

Give examples of the various factors that contribute to error in the health care setting.

Explain why addressing these contributory factors is critical to ensuring the safety of patients and providers.

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Slide 4 Human Factors

The science of “human factors” is the study of “the interrelationship between humans, the tools and

equipment they use in the workplace, and the environment in which they work”

Source: WHO Patient Safety Curriculum Guide for Medical Schools. Geneva, Switzerland: World Health Organization; 2008:99.

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Slide 5 Human Factors

Human factors engineering applies what we know about our capabilities and limitations to the design of

products, processes and our work environment

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Slide 6 Levels of Human Factors or Ergonomics

• Human-machine: Hardware ergonomics

• Human-environment: Environmental ergomonics

• Human-software: Cognitive ergonomics

• Human-job: Design ergonomics

• Human-organization: Macroergonomics

Source: Hendrick, HW. Organizational design and macroeconomics. In: Salvendy, G, editor. Handbook of Human Factors and Ergonomics. New York: John Wiley & Sons, 1997. pp.594-636.

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Slide 7 Human Factors

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Slide 8 Human Factors

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Slide 9 Friday morning…or not just Fridays….

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Slide 10 You drive two cars

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Slide 11 Now think about the same situation on the nursing floor

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Are you right or left handed?

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Slide 12 Standardization

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Slide 13 Do we standardize in healthcare?

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Slide 14 Standardization - Color coded wristbands

Started with one report

• Failure to rescue

Isolated incident?

Statewide survey (PA)

• All Hospitals and ASFs

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Slide 15 Standardization - Color coded wristbands

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Source: Pennsylvania Patient Safety Authority, 2005

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Slide 16 Standardization

Are we setting ourselves up to fail?

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Slide 17 Human Factors

Human Conditions

Physiological stresses

Psychological stresses

Human Limitations

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Slide 18 Fatigue

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Slide 19 Fatigue

Fatigue can impact an individual’s performance and personality in a variety of ways, including the following:

Reduce decision-making ability

Prolong response time

Increase lapses in attention

Negatively affect short-term memory

Lessen ability to multitask

Increase irritability, moodiness, and depression

Decrease ability to communicate

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Source: IHI Open School

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Slide 20 Boredom

Boredom coupled with fatigue can lead to sleepiness, which can also affect performance

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Slide 21 How does overtime affect job performance?

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Slide 22 How about stress?

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Slide 23 Military Study

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Slide 24

100%

90%

80%

70%

Time (hours)

1 2 3 4

Perform

ance

Performance Graph (curve)

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Slide 25

100%

90%

80%

70%

Time (hours)

1 2 3 4

Perform

ance

Performance Graph (curve)

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Slide 26 How can we move the curve upwards?

100%

90%

80%

70%

Time (hours)

1 2 3 4

Perform

ance

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Slide 27 How do stressors affect our job performance?

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Slide 28 How do stressors affect our job performance?

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Slide 29 Poor Package Design

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Slide 30 Poor Design

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Slide 31 Poor Packaging Design

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Slide 32 Medication Vial Packaging

Original Design Redesign

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Slide 33 Poor brand name usage

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Slide 34 Product Design

Here is an example of a feeding pump device that was poorly designed because it always displays 3 digits.

The feed interval (bottom image) is programmed for 6 hours, but the device displays this as 6.00, an example of “trailing zeros.” This could easily be mistaken for 600.

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Slide 35 Can design affect patient safety?

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Slide 36 Workarounds: A Sign of Opportunity Knocking

What is a workaround?

Examples

Real value learned

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Slide 37 Workarounds

Humulin regular insulin was administered instead of Humalog (2 doses) as ordered. The Pyxis system

was overridden to obtain the Humulin regular insulin due to a delay in the Humalog medication

being profiled in Pyxis.

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Source: PA PSRS Patient Saf Advis 2005 Dec;2(4):25-8.

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Slide 38 Workarounds

Human factors engineering (HFE) concepts can be used to analyze the established system and the workaround.

The goal is to ensure that a system is designed to fulfill the intended purpose and operates as intended. Analyzing workarounds using HFE concepts may help to identify safer and more user friendly system changes.

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Source: Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care 2002;11:352-4.

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Slide 39 What can be done to prevent workarounds?

Policy and procedure review and re-evaluation

Involvement of frontline staff

Near miss reporting

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Slide 40 Strategies to Address Human Factors

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Slide 41 Strategies – Address Human Factors

40 Source: Safety Dog’s Blog, http://safetydoghospital.com/category/force-function/

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Slide 42

“Just Culture Principles: A Response to Human Fallibility,” PowerPoint, California Patient Safety Action Coalition.

• Information

• Equipment/tools

• Design/configuration

• Job/task

• Qualifications/skills

• Perception of risk

• Individual factors

• Environment/facilities

• Organizational environment

• Supervision

• Communication

Design for Human Reliability

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WM1

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Manage through consoling and changes in:

• Processes – double check process for high risk medications to ensure the correct dosage

• Training – regular training and observation for proper patient identification procedures

• Design – re-design a unit to create more efficient workflows

• Environment – may include proper staffing, increased use of clinical support staff, decreasing the number of hours in a shift or limiting the number of days nursing staff work in a row

Source: Lorraine Steefel, “Just Culture System for Nurses Takes Focus of Medical Errors from Penalties to Solutions,” Nurse.com, March 10, 2008, http://news.nurse.com/apps/pbcs.dll/article?AID=/20080310/ONC02/303110014 .

Solutions – Human Error

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• Barriers

• Redundancy

• Recovery

Highly Reliable Design Strategies

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• Barriers are put into place to prevent human error

• Barriers can be administrative or physical

• Design the error out of the system

Barriers Strategy

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• Creation of multiple paths to allow success through a second path if the first path does not work

• Strives to have patients more than one human error away from harm

Redundancy Strategy

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• Refers to our ability to catch an error “upstream” before it can lead to an adverse outcome

• Often achieved with the use of feedback, “downstream test,” or checks

• Based on the premise that processes and the humans engaged in those processes will be fallible

Recovery Strategy

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Slide 48 Red Rules

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Slide 49

A nurse, who was just wrapping up her third 12-hour shift in a row, selected a vial of Lasix from the automatic dispensing system. The tops on the vials of both Lasix and KCL are the same color. She checked the label and administered the medication, which was actually KCL. The patient died. During the investigation, it was discovered that the medication was indeed labeled as KCL, but was inadvertently placed in the Lasix bin. The nurse could not explain how it was missed.

The nurse’s behavior was:

• Acceptable behavior

• Human error

• At-risk behavior

• Reckless behavior

Behavior Quiz

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Slide 50

A pharmacist, who had taken a liking to the new pharmacy tech, stopped wearing his reading glasses at work, including while entering orders and preparing medications. The pharmacist knew that he should wear his glasses at work because he can’t properly read labels or see information on the computer screen without his glasses. He also knows that significant patient harm can occur as a result of his failure to wear his readers.

Is the pharmacist’s behavior:

– Normal behavior

– Human error

– At-risk behavior

– Reckless behavior

Behavior Quiz

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Slide 51 Take-aways

• Simplify

• Standardize

• Automate

• Implement forcing function

• Address

– Design – for high reliability (barriers, redundancy,

recovery)

– Fatigue – recognize, communicate, alleviate

– Stress -

– Boredom – staffing, activities to focus attention

– Workarounds – ask why, opportunity for

improvement

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Slide 52 A final thought…

"We must accept human error as inevitable -and design around that fact."

Donald Berwick, MD, MPP, President and CEO, IHI

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Slide 53

Questions?

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