Post on 28-Dec-2015
Usability and Human Factors
Human Factors and Healthcare
Lecture bThis material (Comp15_Unit4b) was developed by Columbia University, funded by the Department of Health and Human
Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.
Human Factors and HealthcareLearning Objectives
2
• Describe the different dimensions of the concept of human error (Lecture b)
• Describe a systems-centered approach to error and patient safety (Lecture b)
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Lecture b
Patient Safety
http://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_license
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• Healthcare discipline emphasizes reporting, analysis, and prevention of medical error.
• Landmark Report: Institute of Medicine (1999)• Magnitude of the
problem not known
Harvard Medical Practice Study
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Why do Errors Happen?
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• Error is the failure of a planned sequence of mental or physical activities to achieve its intended outcome when these failures cannot be attributed to chance
• Inclination to blame somebody– Who is responsible? Often the person closest to the
failure becomes the one who gets blamed• Can we isolate a single cause?• “When human error is viewed as a cause rather than
a consequence, it serves as a cloak for our ignorance” (Henriksen et al, 2008).
• Systems-centered approach:– Latent Conditions and Active Failures (Reason, 1997)
Active Failure
• Occur at the level of the frontline operator– Effects are felt immediately
• In health care, active errors are committed by providers (e.g., nurses, physicians, pharmacists) who are actively responding to patient needs at the “sharp end”
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Latent Conditions (Reason, 1990)
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Hindsight Bias
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Space Shuttle Challenger Disaster
http://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.html
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• Space shuttle exploded on takeoff in 1986 killing 8 crew members
• Cause: O-ring seal in rocket booster failed at liftoff
• Multiple faults including unanticipated cold weather, brittle O-ring seals, communication problems between NASA and contractors, etc.
• Latent errors went unrecognized
Deepwater Horizon Explosion
http://www.flickr.com/photos/skytruth/4733160839/sizes/l/
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Reason “Swiss Cheese” Model of Error
Reason, J (2000).
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AdverseEvent
OrganizationInfluences Unsafe
Supervision Preconditions for Unsafe Acts
ActiveFailures
LatentFailures
LatentFailures
LatentFailures
• Slips:– Incorrect execution of
a correct action sequence
• Errors when routine behavior is misdirected or omitted
• Mistakes:– Correct execution of
an incorrect action sequence
• Errors in judgment, perception, inference or interpretation
Human Errors
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• Knowledge-Based– Faulty conceptual
knowledge– Incomplete knowledge– Biases and faulty
heuristics– Incorrect selection of
knowledge– Information overload
• Rule-Based– Misapplication of good
rules– Encoding deficiencies
in rules– Action deficiencies in
rules– Dissociation between
knowledge and rules
Mistakes
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Example: Error One
• Description of the environment/case study information:– Mr. B is a 45 year old male being treated for
dehydration secondary to nausea, vomiting and diarrhea
– Mr. B has been in the Intensive care Unit (ICU) for 4 days receiving intravenous fluids via an IV catheter in his right forearm
– As Mr. B stabilizes, the physician orders to start P.O. fluids (fluids by mouth) and discontinue the IV fluids
• Note, the order is to discontinue the IV fluids, not the IV• Typically, the RN will stop the IV fluid and convert the IV to a
saline lock that may be used for intermittent infusions as necessary
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Example: Error One (cont.)
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Example: Error Two
• Mr. Jones is assigned to a team of nurses for the dayshift• One nurse responsible for giving medication to patients on the team• Other nurse responsible for all assessments & treatments• Mr. Jones complains of pain to the treatment nurse• Rather than delay the pain medication waiting for the medication nurse,
treatment nurse obtains narcotic and administers it to Mr. Jones• Treatment nurse forgets to document on medication record that she gave
Mr. Jones some Demerol for pain• When making rounds, medication nurse asks Mr. Jones if he is in pain• Mr. Jones again replies yes• Medication nurse reviews medication record -- no documentation of pain
medication given• She medicates Mr. Jones with Demerol (again)• Within 1 hour, Mr. Jones is lethargic & has respiratory depression• He has to be transferred to ICU for closer monitoring due to Demerol
overdose
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Example: Error Two (cont.)
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Interdependence of The Health Care System
• “Healthcare is composed of a large set of interacting systems - paramedic, and emergency, ambulatory, inpatient care and home health care; testing and imaging laboratories; pharmacies that are connected in loosely coupled but intricate networks of individuals, teams procedures, regulations, communications, equipment and devices that function with diffused management in a variable and uncertain environment” (p 158)
» Kohn et al, (2000)To Err is Human
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Systems Approach to Adverse Events in Health Care
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Lecture b
External Environment
Knowledge Base
Demographics
New Technology
Gov’t Initiatives
Economic Pressures
Health Care Policies
Public Awareness
Political Climate
Management
Patient Load
Staffing
Organization/Safety Culture
Accessibility of Personnel
Leadership Involvement
Physical Environment
Lighting
Noise
Workplace Layout
Distractions
Human-System Interface
Medical Devices
Equipment Location
Controls and Displays
Paper/electronic Charts
Distractions
Org/Social Environment
Authority Gradients
Group Norms
Communication/Coordination
Local Procedures
Work Life Quality
Systems Approach to Adverse Events Continued
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Nature of the Work
Treatment Complexity
Workflow
Individual vs. teamwork
Competing Tasks and interruptions
Physical/Cognitive Requirements
Individual Characteristics
Knowledge/Skills
Experience
Physical Capabilities
Alertness/fatigue
Motivation/Attitude
Cultural Competency
AcceptablePerformance
Sub-StandardPerformance
PredictableAdverse Event
1.2 Chart: (Henriksen, 2008)
Medical Errors
1.3 Chart: (Zhang et al, 2004)
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Near Miss
Boundary
Normal Routine
Adverse Event ReportBoundary
Violation of consensual bounds of safe practice Error recovery: Detection and
correction of violation
Human Factors and HealthcareSummary – Lecture b
• Patient Safety and human error
• Reason model of error– Slips and mistakes– Knowledge vs rule-based mistakes
• Systems approach to medical error
• Next lecture: Workload, medical devices and mental models
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Human Factors and HealthcareReferences – Lecture b
Reference
Carayon, P. (Ed.). (2007). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ: Lawrence Erlbaum Associates.
Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding Adverse Events: A Human Factors Framework. In H. R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 84-101). Rockville, MD: Agency for Healthcare Research and Quality
Horsky, J., Kaufman, D.R., Oppenheim, M.I. & Patel, V.L. (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. Journal of Biomedical Informatics, 36, 4-22.
Kaufman, D. R., Pevzner, J., Rodriguez, M., Cimino, J. J., Ebner, S., Fields, L., et al. (2009). Understanding workflow in telehealth video visits: Observations from the IDEATel project. Journal of Biomedical Informatics, 42(4), 581-592.
Kaufman, D.R. & Starren, J. B. (2006). A methodological framework for evaluating mobile health devices. In the Proceedings of the American Medical Informatics Annual Fall Symposium. Philadelphia: Hanley & Belfus. 978
Kaufman, D.R., Patel, V.L., Hilliman, C., Morin, P.C., Pevzner, J, Weinstock, Goland, R. Shea, S. & Starren, J. (2003). Usability in the real world: Assessing medical information technologies in patients ’ homes. Journal of Biomedical Informatics, 36, 45-60.
Reason, J.T. (1997) Managing the risks of organizational accidents. Ashgate Pub;ishing, Aldershot, UK.
Reason, J.T. (1990) Human Error. Cambridge University Press, Cambridge.
Kohn, L.T., Corrigan, J., and Donaldson, M. (2000). To Err is Human. Institute of Medicince, National Academy Press. Washington, Dc.
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Human Factors and HealthcareReferences – Lecture b
Images
Slide 3: Retrieved on September 10th, 2010 from http://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_license
Slide 9: Retrieved on September 10th, 2010 from http://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.html
Slide 10: Retrieved on September 10th, 2010 from http://www.flickr.com/photos/skytruth/4733160839/sizes/l/
Slide 11: Reason J (2000). Human error: models and management. BMJ, 320:768-70
Charts, Tables and Figures
1.1 & 1.2 Chart: Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding Adverse Events: A Human Factors Framework. In H. R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 84-101). Rockville, MD: Agency for Healthcare Research and Quality
1.3 Chart: Zhang, J., Patel, V. L., Johnson, T. R., & Shortliffe, E. H. (2004). A cognitive taxonomy of medical errors. J Biomed Inform, 37(3), 193-204.
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Lecture b