Human Factors and Patient Safety

Transcription

1 Human Factors and Patient Safety Frank Federico, RPh This presenter has nothing to disclose. 8 October 2015

2 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 Discussion What are some key features of a good design? What is it about a design that makes a piece of equipment or a process easy or difficult to use? If not easy to use, how would you modify the design? Insert some examples of poor or good design.

4 Human Error 4 1. Errors are common 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, 1994

5 Human Factors Human Factors Engineering: Examines a particular activity in terms of its component tasks and then considers each task in terms of: physical demands, adequate lighting, skill demands, mental workload, and other such factors limited noise, or other distractions device design, and team dynamics

6 Human Factors 6 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

7 What is the study of Human Factors? Human factors, human factors engineering and ergonomics are often used interchangeably Human factors seeks to understand and design systems that take human limitations into account, supporting people in areas we know to be challenging and capitalizing on human strengths. Poor design is in the eye of the beholder such as human factors professionals

8 Our Focus Understanding the violations of human factors principles that set us up for errors Determining what to do to address these violations (building a better bus!) 8

9 Think of Systems People tend to spend time looking at individual problems without stepping back to see how all the individual pieces fit together in the larger scheme of things.

10 Case Nurse administers incorrect medication Root Causes Analysis completed. Nurse read label incorrectly Deeper investigation Short staffed Nurse caring for three very sick and intense patients Nurse interrupted repeatedly while on medication rounds Changes: Training and education on 6 rights Font on medication label increased. Did this solve the problem?

11 Case Parenteral solutions administered via wrong route Changes Training and education Labels on tubing Be more vigilant

12 Case Jim Taylor Immediately scheduled for surgery to repair the femur Night shift Focus on his agitation Change in vital signs Changes Focus on DVT prophylaxis process only Retraining of nurses on DVT issues

13 What did the proposed changes miss?

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15 Interruptions Fatigue Poor Design Overconfidence FAILURES

16 What Impacts Our Performance? Overestimate abilities Underestimate limitations External stimuli Noise Distractions Environmental conditions Internal response to stress Release of stress hormones Anxiety Increased heart rate

17 Error-Producing Conditions Unfamiliarity with task x17 Shortage of time x11 Poor communication x10 Information overload x 6 Misperception of risk (drift) x 4 Inadequate procedures / workflow x 3 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. Handbook of Human Factors and Ergonomics Gavriel Salvendy

18 Capacity or Complexity Human factors engineering research shows that what is important is not the number of tasks but the nature of the tasks being attempted. An example: A doctor may be able to tell a student the steps in a simple operation while he is doing one but if it was a complicated case he may not be able to do that because she/he has to concentrate.

19 Human Factors Violations: Drivers of Human Error Fatigue Lack of sleep Illness Drugs or alcohol Boredom, frustration Cognitive shortcuts Fear Stress Shift work Reliance on memory Reliance on vigilance Interruptions & distractions Noise Heat Clutter Motion Lighting Too many handoffs Unnatural workflow Procedures or devices designed in an accident prone fashion 19

20 Fatigue Two factors with the most impact are fatigue and stress. Prolonged work has been shown to produce the same deterioration in performance as a person with a blood alcohol level of 0.05 mmol/l, which would make it illegal to drive a car in many countries

21 Shift Work Truck drivers are typically allowed to work no more than 10 hours at a time and no more than 60 hours in one week. Airline pilots and air traffic controllers work regulated hours and some data suggest waning performance as work-hours increase. No studies that evaluated direction of shift work rotation among medical personnel Sleep deprivation and disturbances of circadian rhythm lead to fatigue, decreased alertness, and poor performance on standardized testing. No testing in healthcare workers

22 Shift Work The direction of shift rotation may impact worker fatigue. A forward rotation of shift work (morning shifts followed by evening shifts followed by night shifts) may lead to less fatigue on the job than backward rotation (day shift to night shift to evening shift).

23 Stress While high stress is something that everyone can relate to, it is important to recognize that low levels of stress are also counterproductive, as this can lead to boredom and failure to attend to a task with appropriate vigilance.

24 Reliance on Memory Working memory is limited, and when attention is drawn elsewhere, it can be especially vulnerable

25 Short Term Memory Do you easily remember things like medical record numbers or verbal orders? What do you think would happen if you were interrupted or distracted while remembering these things? Why do you think you forget this information?

26 Long Term Memory Long term memory is where people store facts about the world and how to do things. Mental models are used to store this information and it can be retrieved either by recalling it or recognizing it A phone number A song Directions Recipe

27 Attention Attention describes the ability to concentrate on someone or something. Attention is limited and so those stimuli that are ignored will never get processed by the brain. Instead what is ignored will go unnoticed and will not be remembered.

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31 Attention Multitasking Interruptions Adverse events can occur when the available cognitive resources such as memory are insufficient for the task at hand. IT Current generation clinical ITs are designed with the implicit assumption that their users are carrying out a single task and that their attention is devoted entirely to the interaction with the technology.

32 Error Reduction Overview: Hierarchy of Controls 32 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 Doug Bonacum

33 Specific Error Reduction Strategies 33 Use visual controls Avoid reliance on memory Simplify and Standardize Use constraints/forcing functions Use protocols and checklists Improve access to information Reduce handoffs Decrease look-alike / sound-alikes Automate carefully Reduce interruptions and distractions Take advantage of habits and patterns Promote effective team functioning

34 Usability Testing Usability testing is also essential for identifying workarounds the consistent bypassing of policies or safety procedures by frontline workers. Workarounds frequently arise because of flawed or poorly designed systems that actually increase the time necessary for workers to complete a task. As a result, frontline personnel work around the system in order to get work done efficiently.

35 Ease of Use The design of a process or device should provide visual clues as to how the process should flow or the piece of equipment is to be used The environment should give clues about how to interact with the process or equipment. 1. Norman, The Design of Everyday Things

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39 Forcing functions An aspect of a design that prevents an unintended or undesirable action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first putting his or her foot on the brake pedal.

40 Anesthesia Mix up of gases Changed connectors for different gases Mix up of gases no longer a problem.

41 Tubing Connections Figure 1. Tube delivering oxygen fell off nebulizer Figure 2. The oxygen tubing was connected to a Baxter Clearlink needleless port.

42 Affordances Perceived and actual properties of technologies that determine how they might be used. For example, if someone sees a button, he/she assumes it must be pressed rather than trying to slide or turn a button to get it to work.

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45 Standardization An axiom of human factors engineering is that equipment and processes should be standardized whenever possible, in order to increase reliability, improve information flow, and minimize cross-training needs. Standardized equipment across clinical settings as in the defibrillator Standardized processes such as the use of checklists

46 Environmental Cues Enhance an individual s capacity to recover from interruption. When calculating a drug dose on paper, The paper acts as a cue to help a clinician re-engage with the task after an interruption, Recalling their position in the task sequence and recording intermediate calculations and initial data.

47 The Case of Nifedipine Gel

48 Simplicity of Design

49 Use Visual Controls 49 Which dial turns on the burner? Stove A Stove B

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52 Avoid Reliance on Memory Computerized drug-drug interaction checking Drug information databases Customized drug rules Preprinted orders Chemotherapy order form Pain management order forms 52

53 Simplify Formulary restrictions Remove items Eliminate therapeutic duplications Limit availability Heparin weight based protocol Simplifies ordering process Provides comprehensive orders 53

54 Why Simplify Workflow? STEP 1 STEP 2 STEP 3 STEP 4 90% 90% 90% 90% First step = 90% Process reliability = 90% * 90% * 90% * 90% = 66% 54

55 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 55

56 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 56

57 Improve Access to Information Include Indication with orders/prescriptions Drug information sources Determine ease of use Location of medication list/problem list 57

58 Reduce Handovers Pharmacists on rounds MD and Pharmacist interact directly Increases likelihood of the correct order Reduces delays caused by problematic orders Communicating critical test results Communicate directly with ordering provider 58

59 Strategy: Avoid Look-alike/Sound-alike Drug Names Display lists of easily confused drug names How effective? Strongly encourage Writing prescriptions more clearly Printing in block letters rather than writing in cursive Avoiding the use of abbreviations Indicating the reason for the drug 59

60 Automate Carefully Errors multiply if input is incorrect Automated dispensing machines Computerized physician order entry 60

61 Reduce Interruptions and Distractions 61

62 Reduce Interruptions and Distractions Ask: What are critical alarms? Are personal phones best way to help nurses? Have you thought about patient comfort? How many alerts pop-up in a computer system during order entry? Is there a quiet zone for medication administration? (e.g. Green Vest at KP) 62

63 Take Advantage of Habits and Patterns Identifying high risk patients in the office setting Engage patients while waiting Hand hygiene Must become part of behaviors Habit 63

64 Habits and Patterns (Continued) Patient medication list Sleeve to hold insurance card and medication list 64

65 Hand Hygiene 65 Using a nudge instead of a rule Nudge theory is mainly concerned with the design of choices, which influences the decisions we make. Nudge theory proposes that the designing of choices should be based on how people actually think and decide (instinctively and rather irrationally), rather than how leaders and authorities traditionally (and typically incorrectly) believe people think and decide (logically and rationally).

66 Promote Effective Team Functioning 66

67 Listening Exercise 67

68 Please decide if the following statements are true, false or? (unable to determine with the information given) 68 A man appeared after the owner had True /False /? turned off his store lights The robber was a man. The robber did not demand money. The owner opened the cash register. True /False/? True/False/? True /False/? After the man who demanded the money scooped up the contents of the cash register, he ran away. True /False/? While the cash register contained money, the story does not state how much. True /False/? Steve Kerr, GE

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70 What are the technologies employed at your hospital? Computerized prescriber order entry Electronic medication administration records SMART Pumps Robotic dispensing Ventilators Defibrillators Anesthesia machine Bar code technology Radio Frequency Devices Automated dispensing machines Diagnostic equipment And..

71 Global Problems with Technology Magical thinking It starts something like this: Let s have technology do that. What does this type of thinking miss? Can you think of examples of magical thinking?

72 The Problem Sometimes it is in the design Sometimes it is in the interface with users Sometimes it is in the implementation Sometimes it is in how applied Sometimes it is in our expectations Sometimes it is a mismatches between system workflow and clinical workflow

73 Implementation Failure to understand the adaptive nature of implementation is no doubt one of the main reasons health IT systems flounder post-installation. The implementation work required when new information systems are installed also provides an opportunity for redesign and optimization of existing clinical processes Clinical processes, work practices and their supporting technologies probably need to be designed with a useby date.

74 Automation Bias When humans delegate tasks to a computer system they may also shed task responsibility Computer users may then take themselves out of the decision loop

75 Automation Bias Automation bias or automation-induced complacency is a very specific bias associated with computerized decision support and monitoring technologies A user can make either errors of omission (they miss events because the system did not prompt them to take notice) or A user can make errors of commission (they did what the decision system told them to do, even when it contradicts their training and available data)

76 Socio-technical Aspect The socio-technical nature of IT means that the technology and the context within which it is used cannot be separated

77 The Impact of the Automated Automobile

78 The Monk and the Help Desk

79 Tendency to underestimate the complexity embedded in paper The problem with making the transition from the paper world to the electronic world is that in the paper world a lot of things happen by convention & understanding implementing the electronic tools to make that happen is a bigger deal than I think anybody expects. Chair, Medical Informatics Committee Evanston Northwestern Healthcare

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83 Alarm-related Deaths According to The Joint Commission, there were 80 alarm-related deaths in the U.S. between January 2009 and June 2012.

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85 MGH Death Spurs Review of Patient Monitors A Massachusetts General Hospital patient died last month after the alarm on a heart monitor was inadvertently left off, delaying the response of nurses and doctors to the patient s medical crisis.

86 Hospitals don t turn up the volume, lower the noise. Noise in health care facilities has increased by multiples in past decades, and it has a negative effect on health in several ways, not only through missed alarms. These include increased stress and disrupted sleep for patients, lost privacy, communication errors, and clinician burn-out. SoundEar _turn_up_the_volume_lower_the_noise/

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88 In order to achieve effective alarm management Must deal with culture Must use a multidisciplinary approach Develop appropriate processes One size does not fit all

89 What Can You Do? Include human factors analysis in incident investigations Conduct human factors review of organization Are processes standardized? Is there ready access to information? Are redundancies and reminders in place? Conduct a human factors task analysis How many interruptions are there during the work shift? How complex are the tasks or instructions? 89

90 Usability testing Human factors engineers test new systems and equipment under real-world conditions as much as possible, in order to identify unintended consequences of new technology. Example of the clinical applicability of usability testing involves electronic medical records and computerized provider order entry (CPOE). A seminal study found increased mortality in a pediatric intensive care unit after implementation of a commercial CPOE system, attributable in part to an unnecessarily cumbersome order entry process that reduced clinicians' availability at the bedside

91 What Can You Do? Conduct human factors audits Noise levels; distractions; design of workspace; label format; work hours review; shift reviews Train staff: Self-awareness of human factors issues Staff in position to monitor ongoing situations Information overload Back to back shifts or only short breaks between shifts 91

92 Role of Leaders Proper review of new technology for usability Encourage reporting of technology-related errors and defects Include examination of human factors and technology design after an adverse event Obtain feedback from users Look for workarounds that may indicate technology or processes not easy to use

93 Recommendation You can play an integral role in ensuring that the organization has a plan to evaluate where to dedicate resources Done by including technology as part of strategy Important because technology is part of structure Technology can introduce a whole new set of problems Think of unintended consequences

94 VA National Patient Safety Center 94

95 We can t change the human condition, but we can change the conditions under which humans work. James Reason 95

96 Take a moment to reflect on your own work. What will you incorporate from this session into your plans?