SAS Conference 5 November 2018

Transcription

1 Supporting Patent Safety- Team Resource Management & Human Factors and Ergonomics SAS Conference 5 November 2018 Professor Pramod K Luthra Associate Dean HEE NW Visiting Professor MMU & EHU

2 Safety Safety is the state in which the risk of harm to persons or property damage is reduced to, and maintained at or below, an acceptable level through a continuing process of hazard identification and risk management..to err is human Alexander Pope ( ).all men are liable to error John Locke ( )

3 Concept of Safety

4 The Evolution of Safety Thinking in Aviation Technical Factors Human Factors Organisational Factors

5 Characteristics of a safety culture identified by James Reason (1997) Informed managers should know what is going on and workforce willing to report own errors and near misses. Wary all should look for the unexpected and be vigilant. Just have a no blame culture within constraints that some actions are totally unacceptable. Flexible can provide high tempo and routine modes. Can change when circumstances require. Learning be ready to learn in order to improve and capable of implementing what needs to be done for reform.

6 Team Resource Management Definition - is the utilisation of all available human, information & equipment resources towards effective and safe patient care. It studies the application of human factors knowledge by individual members of the team and their interaction as a team.

7 Objectives of TRM Enhance the communication and management skills of the team by the effective utilisation of all available resources to achieve safe and efficient practices Increase knowledge and awareness of human factors which could cause or exacerbate incidents To develop TRM knowledge skills and attitudes, which: when applied appropriately could extricate a person from incipient accidents and incidents when integrated throughout every facet of the organisation culture may prevent the onset of incidents and potential accidents

8 TRM learning encompasses Interpersonal relationships Leadership Working together and relying on the internal & external team. Communication and feedback Personality and behaviour Stress management Decision making

9 Safety and efficiency requires a team effort Wider Team involved which is more than the team on the scene.

10 Human Factors Human factors is a broad discipline which studies the relationship between human behaviour, system design and safety. National Patient safety Association

11 Human Factors & Ergonomics Ergonomics (or Human Factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human well-being and overall system performance. The Institute of Ergonomics and Human Factors (UK) (Loughborough)

12 Human Factors in Clinical Environments Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviourand abilities, and application of that knowledge in clinical settings. Dr Ken Catchpole, a Human Factors in healthcare expert

13 Why do we need to be aware of Human Factor USA 44,000 98,000 deaths /yr Cost $17 29 billion Australia 18,000 deaths/yr Cost A$ 4.7 billion UK 8% deaths/yr Cost 1 billion

14 Medical error in UK National Patient Safety Agency, 2010 Total incidents 1,139,774 Moderate harm 69,154 Severe harm 6,783 Death 2,867 Human factors form part of error chain 70% 4748 cases of severe harm 2000 deaths Human factors are attributable at - the individual level - the organisational level - or more commonly both

15 Human factors Embed Human factors education into all Skills training (taken from air industry education & used in healthcare) Intro of HF, Clinical skills & procedures Quality assurance, best practice, innovation Induction to area, role and team Human Factors (HF) and Ergonomics at individual, team and organisational level Developing speciality skills Patient safety and Quality care Develop HF & clinical skills in teams Values and behaviours knowledge, clinical skills, and procedures, HF Education Strategy for organisation Educator development programme Impact and outcomes, continuous improvement Common core learning resources

16 Our learning Objectives Why do mistakes occur? Review how failures can be identified by root cause analysis Plan what could be done to prevent this happening again Highlight the importance of a culture of safety in any organisation

17 Causes of Human Error Deliberate harm (very rare) Active errors [the sharp end ] omistakes (rule/knowledge based) oslips & lapses (skills based) oviolations (routine, situational or exceptional) Latent errors [the blunt end ] oorganisational decisions and management practices

18 Beliefs and Violations I can handle it I can get away with it I can t help it Everyone does it It s what they [the organisation] really want They will turn a blind eye From James Reason - The Human Contribution p.57

19 Violations

20 Swiss Cheese Model- illustrated Source: Charles Vincent, Patient Safety (2010)

21 Conceptual model of Human Factors SHELL model Software- procedures, symbology, SOPs, protocols Hardware- machine, H-L situations- ergonomics Environment- situation in which S-H-L must function, heating, cold, humid, dark, bio-rythms Liveware- human, physical, sleep, fatigue L-L situation- teams, leadership, culture

22 SHELL model

23 Liveware- Human Physical needs Information processing Environmental tolerance

24 Liveware- Hardware interface Machine/equipment ergonomics Physical size & shape Sensory & information processing eg. monitoring equipment, warning lights Work space eg. operating theatre, clinics etc.

25 Liveware-Software interface Document design Symbols & computer programs Procedures eg. SOPs, drills Rules & regulations i.e. organisation & relevant statutory bodies

26 Liveware Environment interface Disturbed biological rhythms Sleep disturbance and deprivation Heat, cold, humid, light & dark

27 Liveware Liveware interface Interface between people Leadership Teamwork & Co-operation Personality interface Corporate culture & climate Staff/management relationships Pressures conflict

28 Errors cannot be eradicated Aim is to reduce / capture errors to prevent human events

29 Case for study

30 Threats and errors identified Why did they arise in the first place? Contributory factors What would you do? The culture of the organisation

31 Individual (when error is likely) Fatigue Stress Illness Overload Inexperience Complacency Time pressure

32 I M SAFE Illness Medication Stress Alcohol Fatigue Emotions Global Air Training Ltd 2010

33 Stress Any physical, psychological or social pressures, that when applied to a system, causes some significant modification of its form. Stress results from the imposition of any demand or set of demands which require us to react, adapt or behave in a particular manner in order to cope with or satisfy them (CAP 737) Psychological Physical

34 Situational Awareness Human factors are contributing factor in majority of all incidents And over 80% of these are due to loss of Situational Awareness

35 Internal External Direct Perception Stress and Workload Comprehension Interface design Projection Automation Perceived Goals System capability Indirect Innate abilities Doctrines Experience Rules Actual Goals Procedures Table: Factors affecting SA.

36 What helps enhance SA Experience- past experience or knowledge Expectations- are more prepared Briefing prepares and focuses mind and provides shared mental model Communication- between team members Vigilance- active monitoring of situation/instruments

37 Team/individual Communicates effectively Is knowledgeable Understands when errors are more likely Raises concerns Follows procedures Uses cognitive aids Reports incidents /near misses

38 Organisation Trains and develops team / individuals Learns from error / success Looks for latent errors Communicates what it learns Designs systems and process with HF in mind

39 Error Chain

40 To err is human To cover up is inexcusable To fail to learn is unforgivable

41 What is culture? Binds people together as members of groups or teams Clues as to how to behave Influences Values Beliefs Behaviours

42 Just culture In the 90 s notion of no blame culture to encourage reporting and owning up to errors. This indirectly absolved them of all responsibility for their actions no sanctions. More recently replaced by Just culture clear lines drawn with sanctions for behaviour that is unacceptable - Encourages owning up but also ensures people must feel responsible for their others safety.

43 Evolution of safety culture (Westrum 1991) Levels of Maturity (Parker & Hudson 2001) Pathological why waste time on safety Reactive think of safety after an incident Bureaucratic tick box to satisfy auditors Proactive place high value on safety Generative safety is integral

44 Pathological (who cares as long as a we re not caught) Messengers are shot Information is hidden Responsibilities are shirked Failure is covered up New ideas are actively crushed

45 Reactive (Safety is important, we do it every time we have an incident) Investigate once incident reported New policy is developed as necessary Implementation varied

46 Calculative/Bureaucratic (We have systems in place to manage all hazards) Messengers are tolerated Responsibility is compartmentalised Information may be ignored Organisation is just and merciful New ideas create problems

47 Proactive (We work on the problems we find) Look for potential risks Staff are provided training Action is taking regularly and reviewed

48 Generative (safety is how we do business) Information is actively sought Messengers are trained (mandatory?) Responsibilities are shared Failure causes inquiry New ideas are welcomed Full implementation of what needs to be done to reform

49 Thank you