Applying Human Factors to Healthcare Systems Safety

Transcription

1 April 29 th, 2014 To Better is Human TM Applying Human Factors to Healthcare Systems Safety A. Zach Hettinger, MD MS Medical Director National Center for Human Factors in Healthcare MedStar Institute for Innovation (MI2), MedStar Health Research Institute Assistant Professor of Emergency Medicine Georgetown University School of Medicine 1

2 Disclosures Root Cause Analysis Emergency Medicine Patient Safety Foundation Latham Foundation American Society for Healthcare Risk Mgt (ASHRM) Other Funding Agency for Healthcare Research & Quality Office of the National Coordinator National Institutes of Health 2

3 Agenda Case What is Human Factors? Concepts in Human Factors Effective & Sustainable Solutions Skill/Rule/Knowledge Based Errors Just Culture Conclusion 3

4 It starts with a CASE 4

5 Glucometer test result What was the glucose test result? HIGH or LOW? 5

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7 How could you miss it? 7

8 Critical Low: 0.1% of results (119/80,000) 8

9 Who is the expert? Hospital Text of Out of Reportable Range message popup A Critical value; Repeat; Lab Draw for > 600. B RR Lo = result <40; RR Hi = result >600 C D E F Out of range: repeat test to confirm Critical value; repeat within 15 mins; notification required; lab draw for >600 Critical value; you must repeat immediately; STAT glucose Lab draw for RR HI Repeat test CRITICAL VALUE; REPEAT TEST: NOTIFY MD/RN 9

10 What is HUMAN FACTORS 10

11 What is Human Factors Engineering? Designing.. systems, process, and devices.with regards to what humans do well. 11

12 What is Human Factors Engineering? and what we do with variability.. 12

13 Human Factors Engineering We don t redesign humans; We redesign the system within which humans work 13

14 Human Factors Engineering (HFE) Designing for human use Human-Machine Interface (display, control) Optimizes the relationship between technology and the human user Designs the system to match abilities Data-driven, evidence based Normal in aviation, nuclear, military 14

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21 Ambiguous Signage 21

22 Even Door Design has Real World Consequences 22

23 Human Factors CONCEPTS 23

24 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: Processes Procedures Recurrent training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Re-examining environment Manage through: Remedial action Punitive action Support Coach Sanction Adapted from: David Marx, Just Culture. Outcome Engineering 2008: See also, Just Culture: Balancing Safety and Accountability, Sidney Dekker (2008) 24

25 Applying Human Factors to ROOT CAUSE ANALYSIS 25

26 Study Overview 26

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28 Institutional Definition: Facility wide change that requires a large capital investment Example: Medical image delayed secondary to morbid obesity and lack of access to adequate inhouse imaging. Solution: New bariatric accesible imaging equipment 28

29 Information Technology Structure Definition: Changing features of EHR/Health IT system to change functionality Example: A patient aspirated despite being clinically identified as high risk for aspiration by staff members Solution: Ability to track aspiration precautions through EHR 29

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33 Physical Environment Definition: Changes to the physical environment within which medical staff work Example Case: A patient with anaphylaxis is given 0.5 mg of 1:10,000 epinephrine, instead of 0.3mg of 1:1,000 because the later was not available. Solution: Patient care environments stocked with 1:1000 epinephrine 33

34 Defibrillator Case VF cardiac arrest nurse with patient charges unit clears patient presses on button Machine powers down 2-3 minute delay in shock 34

35 Projectors Don t Kill People

36 Process Definition: Changing the work process and flow of the healthcare workers in an attempt to reduce hazards Example: A post surgical patient aspirates and dies without a swallow evaluation, despite recognition as an aspiration risk by staff. Solution: A standard process/protocol developed to implement aspiration precautions. Aspiration precautions should be the standard of care for all patients with difficulty swallowing. Swallowing study can be done seven days a week 36

37 Forms & Paperwork Definition: New forms or changes to documentation templates and procedures. Example: A critically lab value repeated per protocol, but paper requisition never filed and test not performed. Solution: All lab specimens required to have a requisition/order for testing 37

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39 Review Definition: An assessment of a particular system/process Example: A patient with sepsis (RRT evaluated the day before) was transported to radiology where she died while awaiting transport. Solution: Implement regular RRT case review with staff within 24 hours to provide a feedback loop to identify points in care where interventions could have prevented RRT 39

40 Training Definition: Education is the primary goal of the solution, either of individuals or groups. Example: Critical labs from a dialysis session and a hypotensive episode were not communicated to floor team, leading to a delayed response to a patient s critical lab values. Solution: Dialysis staff to provide written and a verbal report to home unit of any changes in patient status. 40

41 Knowledge-Based Improvisation in unfamiliar environments No routines or rules available to help handle 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) 41

42 Slips and Lapses: Common Policies, Inservices, Discipline, Training, Vigilance Encouraging Mindfulness

43 Example: Skill-based level, humans see patterns 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. 43

44 Medication Labeling 44

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46 Compliance Checks Definition: These solutions are focused on reviews of charts or processes for the purpose of monitoring or regulating a particular process. Case: An elderly woman fell out of bed and broke her hip. Solution: Incorporate hourly rounding into concurrent auditing. 46

47 Policy Definition: Changes that are limited to creating, changing or reinforcing a policy. Case: Due to a patient mix up, a hearing impaired patient received an unnecessary procedure. Solution: The nurse and the transporter must jointly ID the patient prior to the patient leaving the unit. 47

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49 Counseling Definition: The creation of development plan, feedback or referral to practice committee for individuals. Contact Third Parties Definition: The involvement of third parties includes bringing in manufacturers representatives, motivational speakers and other consultants. 49

50 Risk Management Definition: These solutions focus only on the involvement of Risk Management Disciplinary Definition: These solutions focus disciplinary actions taken towards involved staff members. 50

51 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: Processes Procedures Recurrent training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Re-examining environment Manage through: Remedial action Punitive action Support Coach Sanction Adapted from: David Marx, Just Culture. Outcome Engineering 2008: See also, Just Culture: Balancing Safety and Accountability, Sidney Dekker (2008) 51

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53 CONCLUSION 53

54 Staged Sustainability Approach Effectiveness Sustainability 54

55 Take Home Points Staged Approach Generalizability Limiting individual focused solutions Classify the contributing factors and create solution appropriate to the error Consider Implementation of Just Culture 55

56 Be Optimistic _g&feature=youtu.be 56

57 Thank you Terry Fairbanks, MD, MS Amy Bisantz, PhD Vicki Lewis, PhD Robert Wears, MD, PhD John Wreathall, MS Sudeep Hegde, MS Alex Rackoff, MD Kate Kellogg, MD 57

58 Questions? 58

59 TABLETOP EXCERCISE 59

60 Skill/Rule/Knowledge Based Errors Case 1: A new physician is admitting a patient from the emergency department, and places the patient with chest pain on a non-telemetry unit. While waiting to move to the correct floor, the patient has an arrhythmia that is not initially detected and the patient has a poor outcome. Case 2: While performing triage on a patient with stomach pain in the emergency department a nurse uses the standing abdominal pain orders to request lab and urine tests. An hour later the patient is seen by the physician who immediately orders an EKG which shows a STEMI (heart attack) and the patient is rushed to the cardiac catheterization lab. Case 3: A nurse receives an order for clindamycin 300mg PO, obtains the medication from the automated medication system and administers it to the patient after performing the safety checks. Thirty minutes after receiving the medication the patient has an anaphylactic reaction requiring a stay in the ICU. It was later determined that the patient was given Pen VK to which they have a known allergy, and that the medications were stocked in the system incorrectly. 60

61 Knowledge-Based Improvisation in unfamiliar environments No routines or rules available to help handle 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) 61

62 Just Culture Case 1: In an effort to perform all of the patient care duties and documentation, a patient care tech uses barcodes taped to a desk instead of the patient s wrist bands to improve efficiency. Case 2: A medical staff member is known by other members to be disrespectful; when asked about some medical decisions that lead to hazardous situations and patient harm he states I don t care and I ve always done it this way. Case 3: After opening the chart to write an order for antibiotics for a patient with low blood pressure and sepsis (blood infection), a physician is approached by a nurse and asked for pain medications for a different patient. The physician writes the order for Dilaudid 1mg IV for the patient with sepsis that results in a further lowering of their blood pressure and requires additional IV fluids and monitoring. 62

63 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: Processes Procedures Recurrent training Design Environment Manage through: Removing incentives for At- Risk Behaviors Creating incentives for healthy behaviors Increasing situational awareness Re-examining environment Manage through: Remedial action Punitive action Support Coach Sanction Adapted from: David Marx, Just Culture. Outcome Engineering 2008: See also, Just Culture: Balancing Safety and Accountability, Sidney Dekker (2008) 63

64 Sustainable System Solutions Case 1: After an adverse event all staff members are given an in-service on the Patient Controlled Analgesia (PCA) pump (medical device) that has been involved in multiple medication overdoses. Case 2: After multiple observation sessions where medical staff is observed not washing their hands, the team decides to add alcohol-based hand sanitizers outside each patient room. Case 3: A physician is fired after performing a procedure on the wrong side of the patient. 64

65 Questions? 65