Human Factors & Medicines Information Errors

Transcription

1 Human Factors & Medicines Information Errors Dr Hannah Family, Lecturer, Department of Pharmacy &

2 A story of 4 parts Memory & Attention Error Theory Workload & Errors Work design for safety

3 What information is your brain processing?

4 Correct and incorrect responses/ decisions Beliefs, attitudes, values and emotional responses Human Information Processing Task Demands Sensory Register Long Term Memory Working Memory

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6 Situation Awareness (Mica Endsley) State of the environment Feedback Situation Awareness Perceive Understand Think ahead Level 1 Level 2 Level 3 Decision Performance of actions

7 Human Error Theory

8 The Swiss Cheese Model (Reason, 1990; 2000) & The Dynamics of Accidence Causation

9 Latent Conditions (Charles Vincent, 2010) Factor types Influencing contributory factors Examples Work environment Staffing levels & skill mix; workload & shift patterns; design, availability & maintenance of equipment; administrative & managerial support High workload, inadequate staffing or limited access to equipment Team Verbal communication; written communication; supervision & seeking help; team structure Poor communication between staff Individual/staff Knowledge & skills; competence; physical & mental health Lack of knowledge or experience of specific staff Task Task design & clarity of structure; availability and use of protocols; availability & accuracy of test results Non-availability of test results or protocols Patients Condition (complexity & seriousness); language & communication; personality & social factors Distressed patient or language problem

10 Unsafe Acts (Reason, 1990)

11 IRMIS Reports

12 Workload & Errors

13 Mental Workload A multidimensional construct that describes the demands made of an individual s limited information processing capacity. The level of demand made is the product of the interplay between an individual s characteristics, the environment in which the task is carried out and the task characteristics.

14 The Cognitive Systems Model (Grasha 2001) Interpersonal influences Task Demands Extraorganisational influences Personal influences Sensory Register Long Term Memory Organisational influences Working Memory As we gain more experience of a task (expertise) our brain learns the routines, processes and knowledge which we use to carry out a task and stores these mental notes in long-term memory. Reducing our reliance on working memory Correct and incorrect responses/ decisions Beliefs, attitudes, values and emotional responses Environmental influences

15 NASA-TLX Hart & Staveland Mental Workload Rating 1 1. Please rate the MENTAL DEMAND of the task: How much mental and perceptual activity was required? Low High 2. Please rate the PHYSICAL DEMAND of the task: How much physical activity was required? Low High 3. Please rate the TEMPORAL DEMAND of the task: How much time pressure did you feel due to the pace at which the task elements occurred? Low High 4. Please rate your PERFORMANCE: How successful do you think you were in accomplishing the goals of the task? Low High 5. Please rate your EFFORT: How hard did you have to work (mentally and physically) to accomplish your level of performance? Low High 6. Please rate your FRUSTRATION: How discouraged, irritated, stressed and annoyed did you feel during the task? Low High

16 Mental Workload Throughout the Day Peak in performance concern around 7am concern Figure 1: Graph of the NASA-TLX MWL items and pharmacy busyness plotted against time of day

17 Mental Workload Throughout the Day Time pressure Mental demand concern Mental effort Figure 1: Graph of the NASA-TLX MWL items and pharmacy busyness plotted against time of day

18 Mental Workload Throughout the Day Peaks in all facets *except performance* concern Shifts from low to high or high to low volume of work predicted increases in near miss reports (Grasha, 2002) 11am 5pm Figure 1: Graph of the NASA-TLX MWL items and pharmacy busyness plotted against time of day

19 Mental Workload Throughout the Day concern Peaks in time pressure, performance concern and task frustration Dispensing incidents were found to occur during prolonged periods of moderate workload or after a busy period. Possibly due to a fatigue after-effect James et al (2013) 2pm Figure 1: Graph of the NASA-TLX MWL items and pharmacy busyness plotted against time of day

20 Mental workload & Situation Awareness Theoretical framework of the relationship between mental workload and situation awareness (from Tsang & Vidulich, 2006, with permission)

21 Mental workload or Stress? Stress is: a psychological state which is part of and reflects a wider process of interaction between individuals results when and their an work individual environment perceives (Cox, 1993, p29). a discrepancy between the demands of a situation and his/her resources (Sarafino, 2000) Transactional model of stress

22 Transactional model of stress Primary appraisal Is there a threat? YES Secondary appraisal Can I cope with that threat? NO YES NO Psychological distress (Lazarus & Folkman, 1987)

23 Designing work for safety

24 Design work around the way your brain works Human observers are not necessarily aware of all the factors which may lead to an error being made because It happened through an unconscious cognitive process Their actions were part of a chain of events in a system To identify the cognitive processes involved in pharmacy tasks we can use the following methods Failure Modes and Effects Analysis Hierarchical Task Analysis Verbal Protocols and/or Think Aloud studies bad when they use the Route Cause Analysis (already done in practice) Focus groups and interviews same response modes Multi-tasking is particularly (e.g. if both tasks require motor responses) see excellent paper by Wickens (2008) Issues to consider when planning your workload / workforce Time needed to complete each task Can some steps be automated? Skill mix Multi-tasking / competing tasks

25 Strategies for managing mental workload Autonomy and control over workload Having control over one s workload helps sustain mental resources and optimal mental workload (Hockey & Earle, 2006) Breaks Emphasise the importance of breaks and the need to mentally switch off Planning safety critical or demanding tasks to avoid times when mental resources may be lower The first 15minutes after a break First thing in the morning / in the evening After a particularly high period or low period of workload Identify factors which affect your mental workload so you can individually plan around this (there is no one-size fits all model)

26 Managing Interruptions & Distractions Techniques to recover situation awareness on returning to the task marking the point at which a task is disengaged (Boehm-Davis & Remington, 2009) Questions to find your place: Identify (what was I doing?), Ask (where was I interrupted?) Decide/act (what do I need to do to get back on track?) (Airbus, 2004; Boehm-Davis & Remington, 2009)

27 Effective Communication - Phraseology Decimal not point (Civil Aviation Authority, 2013) pdf

28 Effective communication How many pieces of information to give at a time? Readback of key information Reduce Jargon Phonetic alphabet Scripts

29 A Closing Note: Charles Vincent on Patient safety: Patient safety is sometimes equated with preventing error, this seems an innocent enough put is a potentially limiting assumption. There is no question that an understanding of error is fundamental to patient safety; however, there are differences of view as to whether the focus of patient safety research and practice should be on error or harm. (p ) Harm is what patients care about most Not all harm is due to error Many errors do not lead to harm

30 Thank you! Any Questions? Contact me