Slide 1 Human Factors: The Science of Reliability MSHRM February 2015 Anne Huben-Kearney, RN, BSN, MPA, CPHQ, CPHRM Assistant Vice President, Healthcare Risk Management AWAC Services, a member company of Allied World Kathleen Murray, RN, CPHRM, CPPS, FASHRM Assistant Vice President, Healthcare Risk Management AWAC Services, a member company of Allied World Slide 2 Disclaimer This presentation is not intended to be and should not be used as a substitute for legal or medical advice. Rather it is intended to provide general risk management information only. Legal or medical advice should be obtained from qualified counsel to address specific facts and circumstances and to ensure compliance with applicable laws and standards. 1 Slide 3 Human Factors Learning Objectives: Describe the basic concepts of the science of human factors. Identify the causes of error in your everyday life. Give examples of the various factors that contribute to error in the health care setting. Explain why addressing these contributory factors is critical to ensuring the safety of patients and providers. 2
Slide 4 Human Factors The science of human factors is the study of the interrelationship between humans, the tools and equipment they use in the workplace, and the environment in which they work Source: WHO Patient Safety Curriculum Guide for Medical Schools. Geneva, Switzerland: World Health Organization; 2008:99. 3 Slide 5 Human Factors Human factors engineering applies what we know about our capabilities and limitations to the design of products, processes and our work environment 4 Slide 6 Levels of Human Factors or Ergonomics Human-machine: Hardware ergonomics Human-environment: Environmental ergomonics Human-software: Cognitive ergonomics Human-job: Design ergonomics Human-organization: Macroergonomics Source: Hendrick, HW. Organizational design and macroeconomics. In: Salvendy, G, editor. Handbook of Human Factors and Ergonomics. New York: John Wiley & Sons, 1997. pp.594-636. 5
Slide 7 Human Factors 6 Slide 8 Human Factors 7 Slide 9 Friday morning or not just Fridays. 8
Slide 10 You drive two cars 9 Slide 11 Now think about the same situation on the nursing floor Are you right or left handed? 10 Slide 12 Standardization 11
Slide 13 Do we standardize in healthcare? 12 Slide 14 Standardization - Color coded wristbands Started with one report Failure to rescue Isolated incident? Statewide survey (PA) All Hospitals and ASFs 13 Slide 15 Standardization - Color coded wristbands Source: Pennsylvania Patient Safety Authority, 2005 14
Slide 16 Standardization Are we setting ourselves up to fail? 15 Slide 17 Human Factors Human Conditions Physiological stresses Psychological stresses Human Limitations 16 Slide 18 Fatigue 17
Slide 19 Fatigue Fatigue can impact an individual s performance and personality in a variety of ways, including the following: Reduce decision-making ability Prolong response time Increase lapses in attention Negatively affect short-term memory Lessen ability to multitask Increase irritability, moodiness, and depression Decrease ability to communicate Source: IHI Open School 18 Slide 20 Boredom Boredom coupled with fatigue can lead to sleepiness, which can also affect performance 19 Slide 21 How does overtime affect job performance? 20
Performance Slide 22 How about stress? 21 Slide 23 Military Study 22 Slide 24 Performance Graph (curve) 100% 90% 80% 70% 1 2 3 4 Time (hours) 23
Performance Performance Slide 25 Performance Graph (curve) 100% 90% 80% 70% 1 2 3 4 Time (hours) 24 Slide 26 How can we move the curve upwards? 100% 90% 80% 70% 1 2 3 4 Time (hours) 25 Slide 27 How do stressors affect our job performance? 26
Slide 28 How do stressors affect our job performance? 27 Slide 29 Poor Package Design 28 Slide 30 Poor Design 29
Slide 31 Poor Packaging Design 30 Slide 32 Medication Vial Packaging Original Design Redesign Slide 33 Poor brand name usage 32
Slide 34 Product Design Here is an example of a feeding pump device that was poorly designed because it always displays 3 digits. The feed interval (bottom image) is programmed for 6 hours, but the device displays this as 6.00, an example of trailing zeros. This could easily be mistaken for 600. 33 Slide 35 Can design affect patient safety? 34 Slide 36 Workarounds: A Sign of Opportunity Knocking What is a workaround? Examples Real value learned 35
Slide 37 Workarounds Humulin regular insulin was administered instead of Humalog (2 doses) as ordered. The Pyxis system was overridden to obtain the Humulin regular insulin due to a delay in the Humalog medication being profiled in Pyxis. Source: PA PSRS Patient Saf Advis 2005 Dec;2(4):25-8. 36 Slide 38 Workarounds Human factors engineering (HFE) concepts can be used to analyze the established system and the workaround. The goal is to ensure that a system is designed to fulfill the intended purpose and operates as intended. Analyzing workarounds using HFE concepts may help to identify safer and more user friendly system changes. Source: Gosbee J. Human factors engineering and patient safety. Qual Saf Health Care 2002;11:352-4. 37 Slide 39 What can be done to prevent workarounds? Policy and procedure review and reevaluation Involvement of frontline staff Near miss reporting 38
Slide 40 Strategies to Address Human Factors 39 Slide 41 Strategies Address Human Factors 40 Source: Safety Dog s Blog, http://safetydoghospital.com/category/force-function/ Slide 42 Design for Human Reliability WM1 Information Equipment/tools Design/configuration Job/task Qualifications/skills Perception of risk Individual factors Environment/facilities Organizational environment Supervision Communication 41 Just Culture Principles: A Response to Human Fallibility, PowerPoint, California Patient Safety Action Coalition.
Slide 43 Solutions Human Error Manage through consoling and changes in: Processes double check process for high risk medications to ensure the correct dosage Training regular training and observation for proper patient identification procedures Design re-design a unit to create more efficient workflows Environment may include proper staffing, increased use of clinical support staff, decreasing the number of hours in a shift or limiting the number of days nursing staff work in a row Source: Lorraine Steefel, Just Culture System for Nurses Takes Focus of Medical Errors from Penalties to Solutions, Nurse.com, March 10, 2008, http://news.nurse.com/apps/pbcs.dll/article?aid=/20080310/onc02/303110014. 42 Slide 44 Highly Reliable Design Strategies Barriers Redundancy Recovery 43 Slide 45 Barriers Strategy Barriers are put into place to prevent human error Barriers can be administrative or physical Design the error out of the system 44
Slide 46 Redundancy Strategy Creation of multiple paths to allow success through a second path if the first path does not work Strives to have patients more than one human error away from harm 45 Slide 47 Recovery Strategy Refers to our ability to catch an error upstream before it can lead to an adverse outcome Often achieved with the use of feedback, downstream test, or checks Based on the premise that processes and the humans engaged in those processes will be fallible 46 Slide 48 Red Rules 47
Slide 49 Behavior Quiz A nurse, who was just wrapping up her third 12-hour shift in a row, selected a vial of Lasix from the automatic dispensing system. The tops on the vials of both Lasix and KCL are the same color. She checked the label and administered the medication, which was actually KCL. The patient died. During the investigation, it was discovered that the medication was indeed labeled as KCL, but was inadvertently placed in the Lasix bin. The nurse could not explain how it was missed. The nurse s behavior was: Acceptable behavior Human error At-risk behavior Reckless behavior 48 Slide 50 Behavior Quiz A pharmacist, who had taken a liking to the new pharmacy tech, stopped wearing his reading glasses at work, including while entering orders and preparing medications. The pharmacist knew that he should wear his glasses at work because he can t properly read labels or see information on the computer screen without his glasses. He also knows that significant patient harm can occur as a result of his failure to wear his readers. Is the pharmacist s behavior: Normal behavior Human error At-risk behavior Reckless behavior 49 Slide 51 Take-aways Simplify Standardize Automate Implement forcing function Address Design for high reliability (barriers, redundancy, recovery) Fatigue recognize, communicate, alleviate Stress - Boredom staffing, activities to focus attention Workarounds ask why, opportunity for improvement
Slide 52 A final thought "We must accept human error as inevitable - and design around that fact." Donald Berwick, MD, MPP, President and CEO, IHI 51 Slide 53 Questions?