Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

Welcome to Day 3!Please pick up your tent card and sit at your selected table.

“Insanity: doing the same thing over

and over again and expecting different

results.”

Albert Einstein, (attributed)

Human FactorsDoug Bonacum

This presenter has nothing to disclose.

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

3

Session 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

4

Human Error

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

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

5

Human Error Reduction Strategies

“When it comes to shaping on-the-job

performance, there are 2 things that leaders

can influence: The design of work processes

staff use and the behavioral choices they

make to accomplish their work. Both affect

patient safety (and workplace safety and

service and affordability and…).

- adopted from David Marx

6

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

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

7

Our Focus

• Understanding the ‘violations’ of human factors principles that set us up for errors

• Determining what to do to address these violations

8

Nominal Human Error Performance

Redesign with HF in mind

HF Violations

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

Error-Producing Conditions

• Unfamiliarity with task x17• Shortage of time x11• Poor communication x10• Information overload x6• Misperception of risk (drift) x4• Inadequate procedures / workflow x3

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.

10

Human Factors Violations:Drivers of Human Error

• Fatigue• Lack of sleep• Shift work• Boredom,

frustration• Fear • Stress• Reliance on

memory• Reliance on

vigilance• Injury or Illness

• Interruptions & distractions

• Noise• Heat• Clutter• Motion• Lighting• Unnatural workflow• Procedures or

devices designed in an accident prone fashion

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

11

Ve

ry U

nsa

fe S

pa

ce

Nevernever

‘illegalIllegal’space

UsualSpace ofaction

Expected safespace of action asdefined by professionalstandards

Neversometimes

Alwayssometimes

Alwaysalways

ACCIDENT

Market demand

Technology

IndividualConcerns

Performance

Safety regs & good practicesCertification/accreditation standard

How About Our Own Conscious Violations?

Violation Producing Conditions

• Perceived low likelihood of detection

• Inconvenience

• Misperception or lack of recognition of risk

• Authority / status to violate (self-perceived)

• Copying behavior

• No disapproving authority figure present

• Group pressure

{Primary Source Human Error Assessment & Reduction Technique, Jeremy Williams

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

13

Human Factors Engineering (HFE)

• Physical demands

• Skill demands

• Mental workload

• Team dynamics

• Environmental conditions

Human Factors Engineering: Examines a particular activity in terms of its component tasks and then considers each task in terms of:

14

Error Reduction Overview: Hierarchy of Controls

Standardization & Simplification

Policies,Training, Inspection

Minimize consequencesof errors

Make it easy to do the right thing

Make it hard to do the wrong thing

Eliminate the opportunity for error

HumanFactors

Mitigate

Facilitate

Eliminate

Make errors visible

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

15

• Use visual controls

• Avoid reliance on memory

• Simplify and Standardize

• Use constraints/forcing functions

• Use protocols and checklists

• Improve access to information

• Automate carefully

• Reduce interruptions and distractions

• Take advantage of habits and patterns

• Promote effective team functioning

Specific Error Reduction Strategies

16

Stove A

Stove B

Strategy: Use Visual Controls

Which dial turns on the burner?

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

17

18

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

19

• Computerized drug-drug interaction checking

─Drug information databases

─Customized drug rules

• Preprinted orders

─Chemotherapy order form

─Pain management order forms

• Star$$$

Strategy: Avoid Reliance on Memory

20

• Formulary restrictions

─Remove items

─Eliminate therapeutic duplications

─Limit availability

• Heparin weight based protocol

─Simplifies ordering process

─Provides comprehensive orders

• Reduce number of handoffs, number of steps in a process

Strategy: Simplify

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

21

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%

22

• 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

Strategy: Standardize

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

23

• Concentrated KCl vials─Remove KCl from all inpatient units

• Connectors that prevent IV administration of enteral products

• Computer prompt: “Proceed Y or No?”

• And of course, In-N-Out Burger

Strategy: Use Constraints/Forcing Functions

24

• 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

Strategy: Use Protocols and Checklists

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

25

WHO Surgical Safety Checklist

26

• Include “Indication” with orders

• Drug information sources

─Determine ease of use

• Location of medication list/problem list

• Improving Medication Adherence

Strategy: Improve Access to Information

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

27

• Errors multiply if input is incorrect

• Automated dispensing machines

• Computerized physician order entry

Strategy: Automate Carefully

28

Strategy: Reduce Interruptions and Distractions

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

29

Strategy: Take Advantage of Habits and Patterns

• Hand hygiene

• Appointment remindercard - questions

• Patient medication list

─Sleeve to hold insurance

card and

medication list

30

Strategy: Promote Effective Team Functioning

Patient Safety Executive Development ProgramInstitute for Healthcare Improvement

31

What Can You Do?

• Include human factors analysis in incident investigations

• Conduct a human factors task analysis:─Are processes standardized?

─ Is there ready access to information?

─Are redundancies and reminders in place?

─How many interruptions are there during the work shift?

─How complex are the tasks or instructions?

• Educate staff

“We can’t change the human condition, but we can change

the conditions under which humans work.”

James Reason32