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

Transcription

1 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 Factors Doug Bonacum This presenter has nothing to disclose.

2 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 3 1. Errors are common Human Error 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,

3 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 5 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 6

4 Our Focus Understanding the violations of human factors principles that set us up for errors Determining what to do to address these violations 7 Nominal Human Error Performance HF Violations Redesign with HF in mind 8

5 Error-Producing Conditions Unfamiliarity with task Shortage of time Poor communication Information overload Misperception of risk (drift) Inadequate procedures / workflow x17 x11 x10 x6 x4 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

6 How About Our Own Conscious Violations? Safety regs & good practices Certification/accreditation standard Very Unsafe Space Never never illegal Illegal space Never sometimes Usual Space of action Always sometimes Market demand Expected safe space of action as defined by professional standards Always always Technology Individual Concerns ACCIDENT Performance 11 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

7 Human Factors Engineering (HFE) Human Factors Engineering: Examines a particular activity in terms of its component tasks and then considers each task in terms of: Physical demands Skill demands Mental workload Team dynamics Environmental conditions 13 Error Reduction Overview: Hierarchy of Controls Facilitate Mitigate Policies, Training, Inspection Minimize consequences of errors Make errors visible Make it easy to do the right thing Human Factors Make it hard to do the wrong thing Eliminate Eliminate the opportunity for error Standardization & Simplification 14

8 Specific Error Reduction Strategies 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 15 Strategy: Use Visual Controls Which dial turns on the burner? Stove A Stove B 16

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10 Strategy: Avoid Reliance on Memory Computerized drug-drug interaction checking Drug information databases 19 Customized drug rules Preprinted orders Chemotherapy order form Pain management order forms Star$$$ Strategy: Simplify Formulary restrictions Remove items 20 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

11 Why Simplify Workflow? STEP 1 STEP 2 STEP 3 STEP 4 90% 90% 90% 90% First step = 90% 21 Process reliability = 90% * 90% * 90% * 90% = 66% Strategy: Standardize 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 22

12 Strategy: Use Constraints/Forcing Functions 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 23 Strategy: Use Protocols and Checklists 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 24

13 WHO Surgical Safety Checklist 25 Strategy: Improve Access to Information Include Indication with orders Drug information sources Determine ease of use Location of medication list/problem list Improving Medication Adherence 26

14 Strategy: Automate Carefully Errors multiply if input is incorrect Automated dispensing machines Computerized physician order entry 27 Strategy: Reduce Interruptions and Distractions 28

15 Strategy: Take Advantage of Habits and Patterns Hand hygiene Appointment reminder card - questions Patient medication list Sleeve to hold insurance card and medication list 29 Strategy: Promote Effective Team Functioning 30

16 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. 32 James Reason