Human Factors and Ergonomics in Health Care and Patient Safety

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1 Human Factors and Ergonomics in Health Care and Patient Safety Pascale Carayon, Ph.D. Procter & Gamble Bascom Professor in Total Quality Department of Industrial and Systems Engineering Director of the Center for Quality and Productivity Improvement University of Wisconsin-Madison - USA IX International Ergonomics Congress of SEMAC April 2007 Mexico City, Mexico 1of 35

2 What s the problem? US health care expenditures = 13% GNP Institute of Medicine 1999 Report on medical errors and patient safety: 44,000 to 98,000 Americans die in hospitals each year as a result of medical errors. Canada: about 185,000 of the 2.5 million annual hospital admissions associated with an adverse event 2of 35

3 Mexico? 3of 35

4 WHO World Alliance for Patient Safety 4of 35

5 Institute of Medicine-2001 Crossing the Quality Chasm Health care has safety and quality problems because it relies on outmoded systems of work. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes. (p. 4) 5of 35

6 Progress toward understanding patient safety IOM 2000 Report To Err is Human IOM 2001 Report Crossing the Quality Chasm IOM 2003 Report Patient Safety Achieving a New Standard for Care IOM 2003 Report Keeping Patients Safe IOM 2006 Report Preventing Medication Errors Human error / System approaches Design of information technology Importance of human factors 6of 35

7 HFE expertise in healthcare organizations Employee health: occupational safety & health, ergonomics Purchasing of equipment: usability Quality improvement: process analysis Risk management: incident reporting, event analysis OR and critical care: teamwork, communication 7of 35

8 51 chapters: Human error Sociotechnical systems and macroergonomics Technology, medical devices Physical ergonomics Methods and tools Various care settings 8of 35

9 Take-home messages 1. A human factors perspective can provide useful, important information on systemic factors that contribute to patient safety. 2. Need to integrate human factors in the design of healthcare technologies, systems and processes. 9of 35

10 Based on research on human factors in health care and patient safety Funding from the Agency for Healthcare Research and Quality 10 of 35

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12 Leape et al. (1995) Systems analysis of adverse drug events JAMA Causes of medication errors: lack of knowledge of drug faulty dose checking setting up of infusion pump 12 of 35

13 Medication administration technologies 13 of 35

14 Safe Medication Administration through Technologies and Human Factors SMArT HF Aims of the project: 1. To determine the effect of Smart IV Pump technology implementation and integration with BCMA technology on medication errors. 2. To determine the impact of Smart IV pumps and the integration with BCMA technology on end users. 3. To describe a human factors prospective error analysis and to qualitatively evaluate its effectiveness on the implementation success of technology in an acute care hospital setting of 35

15 Multidisciplinary research team Pascale Carayon (PI) Tosha Wetterneck (co-pi) Roger Brown Joshua De Silvey Myra Enloe Ann Schoofs Hundt Qian Li Mark Linzer Tracy Love Brad Ludwig Susan Kleppin Mustafa Ozkaynak Prashant Ram Steve Rough Tanita Roberts Mark Schroeder Sade Sobande 15 of 35

16 Task sequences observed BCMA medication administration START 1 obtain meds scan self 2 scan self enter pt room obtain meds 3 check med vs device scan self check med vs device scan med 4 scan med enter pt room check med vs device scan med double check enter pt room check med vs device enter pt room 5 enter pt room scan pt ID band scan med enter pt room double check by RN scan pt ID band scan med enter pt room scan med enter pt room scan pt ID band scan pt ID band doc admin give med to pt A(1) give med to pt doc admin B(1) scan pt ID band give med to pt doc admin C(2) doc admin D(22) scan pt ID band give med to pt E (1) doc admin give med to pt F (17) give med to patient G(1) scan pt ID band doc admin H(2) doc admin I(1) enter pt room scan pt ID band give med to pt doc admin doc admin give med to pt doc admin enter pt room give med to pt L (1) scan pt ID band give med to pt doc admin M (1) scan pt ID band give med to pt doc admin N (1) scan pt ID band doc admin give med to pt O (1) scan pt ID band give med to pt doc admin P (1) Q(1) doc admin give med to pt R (1) J(1) K(2) 02/04/2006 BCMA = Bar Coding Medication Administration 16 of 35

17 Work system factors observed in BCMA medication administration Technology and Tools Person Organization Tasks: Potentially unsafe med. admin. Person: Patient in isolation Environment: Messy, insufficient light Technology: Automation surprises, malfunctions Organization: interruptions Tasks Environment 17 of 35

18 Leape et al. (1995) Systems analysis of adverse drug events JAMA Technological solution? CPOE = Computerized Provider Order Entry 18 of 35

19 CPOE Implementation in ICUs 19 of 35

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21 Intensive Care Unit (ICU) 21 of 35

22 How does a medication order look like? 22 of 35

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24 CPOE Implementation in ICUs Aims of the project: 1. To determine the effect of CPOE on safety and quality of care in ICUs. 2. To determine the impact of CPOE on end users (physicians, pharmacists, nurses, respiratory therapists) in ICUs. 3. To determine the financial value of CPOE implementation. 4. To examine the impact of prospective human factors error analysis in CPOE implementation of 35

25 Usability training at Geisinger September of 35

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27 178 medication incidents in 7 months 27 of 35

28 Probably the first (modern) study on medication errors was conducted by Alphonse Chapanis (1960). 28 of 35

29 What can we do today so that 40 years from now human factors concepts and methods will have made a difference in the safety of patient care? 29 of 35

30 Understanding the characteristics of health care: Complexity People industry Technology Criticality Variety of care settings: hospital, outpatient, home, Partnership with health care Systemic effects or unintended consequences Impact 30 of 35

31 Need for HFE (intervention) research that will contribute to care that is: safe effective patient-centered timely efficient equitable 31 of 35

32 HFE in Healthcare Delivery Research needs Major issues facing health care and patient safety: Workload of healthcare providers Medical errors and adverse events: identification, management, review, recovery Reliability of systems, processes and technologies Patient safety in a variety of settings Transitions of care Medical devices and healthcare information technology 32 of 35

33 Take-home messages 1. A human factors perspective can provide useful, important information on systemic factors that contribute to patient safety. 2. Need to integrate human factors in the design of healthcare technologies, systems and processes. 33 of 35

34 Lucian Leape in Ergonomics in Design Summer 2004 Given the complexity of health care and the formidable obstacles it presents to change, to overcome those barriers and create a safe culture does indeed seem to be the ultimate challenge for those who specialize in human factors. 34 of 35

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