Systems Thinking & Human Factors Engineering in Healthcare

Transcription

1 Clinical Networks and Streams and Managers John Hunter Hospital Newcastle, NSW; August 10, 2015 Systems Thinking & Human Factors Engineering in Healthcare Rollin J. (Terry) Fairbanks, MD, MS Director, National Center for Human Factors Engineering in Healthcare Director, Simulation & Training Environment Laboratory (SiTEL) MedStar Health, Washington DC, USA Associate Professor of Emergency Medicine, Georgetown University Attending Emergency Physician, MedStar Washington Hospital Center

2 Goal Think Differently. To view safety and risk through the lens of safety science Twitter Discussion: #HFsafety

3 Chart Credit: Modified from L. Leape

4 The Problem USA s Institute of Medicine (IOM) Report: 2000 Govt: 50% less error in 5 years Funding, Regs, High Focus 15 Years later. ESSENTAILLY NO CHANGE WHY? Focus still on individual performance Solutions inconsistent with safety science Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. May ;293(19) Wachter RM. The end of the beginning: Patient Safety Five Years After 'To Err Is Human'. Health Aff. 2004(11) Wachter RM. Patient Safety At Ten: Unmistakable Progress, Troubling Gaps. Health Aff (29:1) Landrigan, Parry, et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. NEJM 363(22): 2010 Shekelle, Pronovost, et al. Advancing the science of patient safety. Ann Int Med 154(10): 2011 Longo, Hewett, Ge, Schubert. The long road to patient safety: a status report on patient safety systems. JAMA, 294(22): 2005.

5 Why No Change? Preoccupation with Human Error Instead of reducing HARM.Leads to ineffective solutions

6 Systems Approach Is the goal: Eliminate Human Error? NO Human Error cannot be eliminated Futile goal; misdirects resources/focus Causes culture of blame and secrecy name, blame, shame, and train mentality It is about reducing HARM

7 Human Factors Engineering We don t redesign humans; We redesign the system within which humans work

8 Cognitive Science (how we think) Industrial and Organizational Psychology (how we collaborate) Work Analysis (how we work now) System Safety Engineering (how we manage risk)

9 809M airline passengers/yr....30,000 flights per day Pilots & ATC: 2 errors per hour

10

11 Example: Defibrillator Case

12 Defibrillator Case VF cardiac arrest nurse with patient charges unit clears patient presses on button Machine powers down 2-3 minute delay in shock

13 Huh? Medical Professionals: Just don t make errors

14 Knowledge-Based Improvisation in unfamiliar environments No routines or rules available Protocolized behavior Process, Procedure Rule-Based Skill-Based Automated Routines Require little conscious attention Figure adapted from: Embrey D. Understanding Human Behaviour and Error, Human Reliability Associates Based on Rasmussen s SRK Model of cognitive control, adapted to explain error by Reason (1990, 2008)

15 Slips and Lapses: Common Policies, Inservices, Signage Discipline, Training, Vigilance, Mindful Moments, etc

16 Defibrillator Case #2 32 year old healthy man Presents to ED with sustained SVT & chest pain Primary interventions unsuccessful Synchronized refractory Try 100j VF Arrest 45m resuscitation attempt patient dies Investigation reveals that MD failed to put device in SYNC mode for second shock

17 Defibrillator Usability Study Two defibrillator models SimMan TM patient simulator 50% of participants inadvertently delivered an unsynchronized countershock for SVT 71% of participants never aware Fairbanks RJ, Caplan SH, et al. Usability Study of Two Common Defibrillators Reveals Hazards. Annals of Emergency Medicine Oct 2007; 50(4):

18 Response #1 Physician should have taken time to ask ED staff for an operator s manual for the defibrillator and read it after he arrived in the ED to perform a cardioversion Fairbanks RJ and Wears RL. Hazards With Medical Devices: the Role of Design. Annals of Emergency Medicine Nov 2008; 52(5):

19 Response #2 the preventative or corrective action is provided in the device labeling Fairbanks RJ and Wears RL. Hazards With Medical Devices: the Role of Design. Annals of Emergency Medicine Nov 2008; 52(5):

20

21

22 Defibrillator Case= COMMON ERROR Trend found in EMS Reporting system Simulation study (Denmark) 72 physicians 5 of 192 defib attempts Turned it off Measurable delay in shock Devices turn off even if charged and ready Hoyer, Christensen, et al. Annals of Emergency Medicine 2008; 52(5): Fairbanks and Wears. Annals of Emergency Medicine 2008; 52(5):

23 Safety Attitudes The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes. --Lucian Leape, Testimony to congress

24 Why is a culture of safety so important? 1 serious or major injury 10 minor injuries 30 property damage injuries 600 incidents with no visible damage or injury Bird, ,753,498 accidents from 297 companies, 21 different industries Slide acknowledgment: Robert Panzer, MD

25 US Airways Non-Reprisal Policy US Airways will not initiate disciplinary proceedings against any employee who discloses an incident or occurrence involving flight safety This policy excludes events known or suspected to involve criminal activity, substance abuse, controlled substances, alcohol, or intentional falsification. Bad Apples Safety

26 Airline Safety Approaches It is vastly more important to identify the hazards and threats to safety, than to identify and punish an individual for a mistake. We exchange the ability to reprimand an individual for the ability to gain greater knowledge. --Jeff Skiles, Miracle on Hudson first officer, On airline safety philosophy

27 Too soft, you say?

28 Just Culture: The Three Behaviors Normal Error At-Risk Behavior Reckless Behavior Inadvertent action: slip, lapse, mistake A choice: risk not recognized or believed justified Conscious disregard of unreasonable risk Manage through changes in: Manage through: Manage through: Processes Procedures Recurrent training Design Environment Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Re-examining environment Griffith University Remedial action Punitive action Support Coach Sanction Adapted from: David Marx, Just Culture. Outcome Engineering 2008: Alternative Perspective: Just Culture: Balancing Safety and Accountability, Sidney Dekker (2008)

29

30 SAFE SYSTEM & PROCESS DESIGN SELECTION, TRAINING, ETC HAZARD REPORTING OPEN SAFETY CULTURE Identify & mitigate Existing hazards Before adverse events occur PATIENT COMPLAINTS

31 Indiana: 5 nurses

32 We See What We Expect To See Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.

33 Healthcare: Complex adaptive system Unordered: Cannot predict cause & Effect & Cannot be modeled or forecasted Ordered & Constrained & Can be reduced to a set of rules Adaptive in that their individual and collective behavior changes as a result of experience Figure: Sardone G, Wong G, 2010; See also: Snowden D, cognitive-edge.com ; Hollnagel, Woods, Leveson 2006; Plsek, Greenhalgh Sardone G, Wong G, Making sense of safety: a complexity based approach to safety interventions. Proceedings of the Association of Canadian Ergonomists 41st Annual Conference, Kelowna, BC, October 2010; 2. Snowden D, cognitive-edge.com 3. Hollnagel, Woods, Leveson 2006

34 Complex Adaptive Systems: work as done vs- work as imagined How managers believe work is being done (rules) GAP Resilience Every-day work: How work IS being done Adapted from: Ivan Pupulidy

35 How the gap reduces margin 12n meds Allow 11a-1p RN compliance Measured Introduce barcoding Patterson ES, et al (2006). Compliance with intended use of bar code medication administration in acute and long-term care. Human Factors, 48(1),

36 Complex Adaptive Systems Imposed solutions may not cover all circumstances They arise from the circumstances (emergence) Relationship between causes & effects can appear evident in retrospect hindsight does not lead to foresight the external conditions and the system itself constantly change. 1. Sardone G, Wong G, Making sense of safety: a complexity based approach to safety interventions. Proceedings of the Association of Canadian Ergonomists 41st Annual Conference, Kelowna, BC, Oct Snowden D, cognitive-edge.com

37 Resilience Engineering Safety I: Why did they give the wrong vial? Safety II: Why did they give the right vial all the other times?

38 People: Sources of Error. or sources of resilience If you weed out all the error prone health professionals, there won t be anyone left

39 sensitive dependence on initial conditions, unruly technology, tipping points, diversity failure emerges opportunistically, nonrandomly, from the very webs of relationships that breed success and that are supposed to protect organizations from disaster.

40 Skills-Based Error = Slips and Lapses = Automaticity Errors HUGE OPPORTUNITY

41 Usability Services Activities

42 GemStar Replacement Project 42

43 CADD Solis No major safety issues found Users able to perform tasks without safety critical errors Clinician user satisfaction not as high as the Sapphire 43

44 Hospira Sapphire 3 major safety hazards found Users observed committing safety-critical errors High user satisfaction 44

45 Glucometer Case Patient with hx of poorly-controlled BG levels Admitted to diabetic unit at hospital Pt appears normal or hyperglycemic Accucheck indicates critically low BG Misinterpreted by tech and RN as critical high Pt given repeated doses of insulin Altered, rapid response called Receives D50, Glucagon, & D10 drip Stays in ICU for 3 days: MAJOR EVENT

46 Nurse SUSPENDED

47 One week later Repeated Incident Same scenario, different unity Multiple RNs, NP involved All misinterpreted critical LO as critical HI Did disciplinary response make us safer?

48 The Second Story Patient has multiple signs of normal-high BG Initial ED values = hyperglycemia I know my sugars, and I m not low Ate all meals, snacks There was an ongoing failure to revise Due to fixation effect and expectations Glucometer design plays into this failure to revise Actions taken initially have no effect Fresh personnel discover true problem

49 Critical Low 0.1% (119/80,000) Within Reportable Range Critical High Critical Low

50

51 How could you miss it?

52 video

53 Procurement: Who determines wording? l Hospital Text of Out Text of of Reportable Out of Reportable Range message Range popup message popup A Critical value; Critical Repeat; value; Lab Repeat; Draw for Lab > Draw 600. for > 600. B RR Lo = result RR Lo <40; = result RR Hi <40; = result RR Hi >600 = result >600 C D E F Out of range: Out repeat of range: test repeat to confirm test to confirm Critical value; Critical repeat value; within repeat 15 mins; within notification 15 mins; notification required; lab required; draw for >600 for >600 Critical value; Critical you value; must repeat you must immediately; repeat immediately; STAT glucose STAT Lab glucose draw for RR HI for RR HI Repeat test Repeat test

54 We See What We Expect To See Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.

55 Video showing impact on the safety culture (Annie s story) 55

56 Fallibility is part of the human condition; We cannot change the human condition; But we can change the conditions under which people work --James Reason, PhD

57 Insanity Continuing to do the same thing and expecting different results. --Einstein

58 Develop Sustainable Solutions Develop Effective Solutions Consider Solutions in Context Focus on HAZARDS

59 3 things leaders can do 1. Shift resources to 1 o and 2 o prevention 2. Implement Just Culture and start the change Senior Leaders to frontline workers 3. Formally implement an event review process based on safety science It will change the culture NPSF s new RCA squared (npsf.org) AHRQ s new CANDOR (Fall 2015 release)

60 Rollin J. (Terry) Fairbanks, MD, MS Director, National Center for Human Factors Engineering in Healthcare Director, Simulation Training & Education Lab (SiTEL) MedStar Institute for Innovation, MedStar Health / Washington DC USA Associate Professor of Emergency Medicine, Georgetown University Attending Emergency Physician, MedStar Washington Hospital Center Fairbanks.au@MedicalHFE.org (until 8/20/15) Terry.Fairbanks@MedicalHFE.org