Human Factors and Patient Safety Frank Federico, RPH Azhar Ali, MD
February 2015 Description Human factors is the study of how humans intact with each other, with equipment, and with the environment. In order to improve patient safety it is necessary to understand the human condition, why we make mistakes and steps that an organization can take to change the conditions under which people make mistakes. These human factors violations are often missed when an adverse event is investigated, During this session, participants will learn about how to become aware of the conditions that contribute to error, learn how to change conditions and incorporate a human factors review into all aspects of their patient safety efforts. 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 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. Human Error Errors are common The causes of errors are known
Many errors are caused by activities that rely on weak aspects of cognition Systems failures are the root causes of most errors Lucian Leape, Error in Medicine JAMA, 1994 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, skill demands, mental workload, and other such factors adequate lighting, limited noise, or other distractions device design, and team dynamics Human Factors 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 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 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!) 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. 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 Response: Training and education on 6 rights Font on medication label increased. Did these solutions solve the problem? Case Parenteral solutions administered via wrong route Changes
Training and education Labels on tubing Be more vigilant Did these solutions solve the problem? What did the proposed changes miss? Interruptions Fatigue Poor Design Overconfidence FAILURES Anesthesia Mix up of gases Changed connectors for different gases
Mix up of gases no longer a problem. 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 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. Error-Producing Conditions
Unfamiliarity with taskx17 Shortage of time x11 Poor communication x10 Information overload x 6 Misperception of risk (drift) x 4 Inadequate procedures / workflowx 3 These are compounded by human factors violationssuch 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 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. Human Factors Violations: Drivers of Human Error
Interruptions & distractions Noise Heat Clutter Motion Lighting Too many handoffs Unnatural workflow Procedures or devices designed in an accident prone fashion Fatigue Lackof sleep Illness Drugs or alcohol Boredom, frustration Cognitive shortcuts Fear Stress Shift work Reliance on memory Reliance on vigilance 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 There is strong scientific evidence linking fatigue and performance decrement making it a known risk factor in patient safety Fatigue 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 Shift Work The direction of shift rotation may impact worker fatigue.
For workers who change from one shift to another, 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). Affordances Affordances are 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. Reliance on Memory Working memory is limited, and when attention is drawn elsewhere, it can be especially vulnerable Short Term Memory How do you 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? 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, such as being able to recite a phone number, or by recognizing it, such as being able to identify a friends number out of a list of phone numbers. 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. Attention Attentional blindness
When people are paying attention to one thing, other things that might seem obvious to others, or that might seem obvious after the fact, can happen right in front of everyone without anyone even realizing it. Selective attention Selective attention, which is also known as cognitive tunneling, occurs when people focus on the things that stand out the most and not necessarily on what is most useful. Attention Focused attention
Focused attention occurs when someone is trying to concentrate on a single stimulus, but other things in the environment make it difficult to focus, causing distraction. Divided attention Divided attention occurs when one attempts to focus on more than one stimulus at once, fully intending to process both stimuli. What Affects Attention?
Alertness and fatigue Multitasking Interruptions Workload Adverse events can occur when the available cognitive resources such as memory are insufficient for the task at hand. Automation Understanding Risk Probability neglect
When strong emotions are triggered by a risk, people show a remarkable tendency to neglect a small probability that the risk will actually come to fruition Carl Sunstein Understanding Risk Risk perception is the subjective judgment people make about the severity and/or probability of a risk, and may vary person to person Heuristics are simple, efficient rules which people often use to form judgments and make decisions. They are mental shortcuts that usually involve focusing on one aspect of a complex problem and ignoring others Carl Sunstein Ergonomics Ergonomics (or human factors) is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimize human well-being and overall system performance. International Ergonomics Association Standardization & Simplification
Error Reduction Overview: Hierarchy of Controls Policies, Training,Inspection Mitigate Human Factors Minimize consequences of errors Make errors visible Facilitate Make it easy to do the right thing Make it hard to do the wrong thing Eliminate the opportunity for error Eliminate Standardization & Simplification Doug Bonacum 42 42 What to do? Usability testing 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 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 Workarounds Usability testing is also essential for identifying workarounds 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. Forcing Functions Forcing functionsAn 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. Forcing functions need not involve device design. Automobiles are now designed so that the driver cannot shift into reverse without first putting his or her foot on the brake pedal. Standardization StandardizationAn 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. Example: checklists Resiliency Resiliency effortsunexpected events can happen
Attention needs to be given to their detection and mitigation before they worsen Resiliency approaches tap into the dynamic aspects of risk management, exploring how organizations anticipate and adapt to changing conditions and recover from system anomalies. Resilience is viewed as a critical system property, Reflects the organization's capacity to bounce back in the face of continuing pressures and challenges when the margins of safety have become thin. Environmental Cues Environmental memory cues, for example, can enhance an individuals capacity to recover from interruption. The Case of Nifedipine Gel Illness IM SAFE (illness, medication, stress, alcohol, fatigue, emotion) that was developed in the aviation industry is useful as a self-assessment technique to determine when entering the workplace each day whether a person is safe for work. Specific Error Reduction Strategies
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 Design of Everyday Things Which dial turns on the burner?
Use Visual Controls Which dial turns on the burner? Stove A Stove B Avoid Reliance on Memory
Computerized drug-drug interaction checking Drug information databases Customized drug rules Preprinted orders Chemotherapy order form Pain management order forms Simplify Formulary restrictions Heparin weight based protocol
Remove items Eliminate therapeutic duplications Limit availability Heparin weight based protocol Simplifies ordering process Provides comprehensive orders Process reliability = 90% * 90% * 90% * 90% = 66%
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% 63 Standardize Who, what, with what, when, where, how Standard solutions
Example from Reliability Session Win / Win - Less work, better care Standard solutions Ease of ordering Ease of preparation Ease of administration Tubing Connections Figure 1. Tube delivering
oxygen fell off nebulizer Figure 2. The oxygen tubing was connected to a Baxter Clearlink needleless port. Tubing Misconnections : Normalization of Deviance, Nutr Clin Pract 2011 26: 286 Use Constraints/Forcing Functions
Concentrated KCl vials Remove KCl from all inpatient units Connectors that prevent IV administration of eternal products Epidural vs. IV vs. Intrathecal connectors Computer prompt: Proceed Y or No? Use Protocols and 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 Improve Access to Information
Include Indication with orders Drug information sources Determine ease of use Location of medication list/problem list Reduce Handoffs 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 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 Automate Carefully Errors multiply if input is incorrect
Automated dispensing machines Computerized physician order entry Reduce Interruptions and Distractions Reduce Interruptions and Distractions
What are critical alarms? Are personal phones best way to help nurses? How many alerts pop-up in a computer system during order entry? Have you thought about patient comfort? Is there a quiet zone for medication administration? (e.g. Green Vest at KP) 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 Habits and Patterns (Continued)
Patient medication list Sleeve to hold insurance card and medication list Hand Hygiene 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). Promote Effective Team Functioning Listening Exercise Please decide if the following statements are true, false or
Please decide if the following statements are true, false or ?(unable to determine with the information given) A man appeared after the owner had True /False /? turned off his store lights The robber was a man True /False/? The man did not demand money True/False/? The owner opened the cash register 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 Technology Global Problems with Technology
Magical thinking It starts something like this: Lets have technology do that. What does this type of thinking miss? Can you think of examples of magical thinking? 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.. Technology Failure to understand the adaptive nature of implementation is no doubt one of the main reasons health IT systems fail after installed. 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 use-by date. Automation Bias Automation bias or automation-induced complacency: specific bias associated with computerized decision support and monitoring technologies Clinical decision support: Errors of omission (they miss events because the system did not prompt them to take notice) or errors of commission (do what told even in data indicates otherwise) Automation Bias Users shed responsibility when default to computer
Delegate responsibility to computer Computer users may then take themselves out of the decision loop Information System Design and Real World
Inadequate or poorly designed user interfaces Incomplete or incorrect assumptions about clinical tasks and mental models Mismatches between system workflow and clinical workflow Socio-technical Aspect
The socio-technical nature : IT and context in which used Implementation will vary from organization to organization based on context Workarounds must be examined Parallel workflows that circumvent the workflow as designed Implementation Many errors only becomes clear when they are considered as a group, and not individually. Implementation is not a technical process Must be seen as IT to users and their workflowsimplementation is redesign. The Impact of the Automated Automobile The Monk and the Help Desk 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 & understandingimplementing the electronic tools to make that happen is a bigger deal than I think anybody expects. Chair, Medical Informatics Committee Evanston Northwestern Healthcare Magic Alarm-related Deaths According to The Joint Commission, there were80 alarm-related deaths in the U.S. between January 2009 and June 2012. 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 patients medical crisis. Hospitals dont 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 Purpose of Alarm Management
Alarms should direct the clinicians attention towards conditions requiring timely assessment or action; Alarms should alert, inform and guide required clinician action; Every alarm should be useful and relevant to the clinician, and have a defined response; Alarm levels should be set such that the clinicians have sufficient time to carry out their defined response before the plant condition escalates; The alarm system should be designed to accommodate human capabilities and limitations 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 Rules of Thumb, Make all facets of design as consistent with user expectations as possible. Both the users previous experience with medical devices and well-established conventions are important considerations. Design workstations, controls, and displays around the basic capabilities of the user, such as strength, dexterity, memory, reach, vision, and hearing. Design well-organized and uncluttered control and display arrangements. Ensure that the association between controls and displays is obvious. This facilitates proper identification and reduces the users memory load. A balanced program attempts to optimize safety, performance and cost.
System safety must be planned. It is an integrated and comprehensive engineering effort that requires a trained staff experienced in the application of safety engineering principles. The effort is interrelated, sequential and continuing throughout all program phases. A balanced program attempts to optimize safety, performance and cost. A correct safety balance cannot be achieved unless acceptable and unacceptable conditions are established early enough in the program to allow for the selection of the optimum design solution and/or operational alternatives. Defining acceptable and unacceptable risk is as important for cost-effective accident prevention as is defining cost and performance parameters. Safety management must be based on the behavior of people and the organizational culture.
Everyone has a responsibility for safety and should participate in safety management efforts. Modern organization safety strategy has progressed from safety by compliance to more of an appropriate concept of prevention by planning. Reliance on compliance could translate to after-the-fact hazard detection, which does not identify organizational errors, that are often times, the contributors to accidents. What Can You Do? Include human factors analysis in incidentinvestigations 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? 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 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 VA National Patient Safety Center
New URL New cognitive aids will be available online by early 2015 We cant change the human condition, but we can change the conditions under which humans work. James Reason Human Factors Exercise
Working Lunch June 4, 2014 Objectives To provide you with the opportunity to identify human factors violations and suggest strategies to address those violations. Exercise We ask you to review one of three cases
Each table will be given one case Read the case and as a team identify the human factors violations Are there underlying conditions that may have contributed to the events? What can you test to address the human factors violations you identified? Human Factors Violations
Fatigue Lackof sleep Illness Drugs or alcohol Boredom Frustration Fear Stress Shift work Reliance on memory Reliance on vigilance Distractions Noise Heat Clutter Motion Lighting Too many handoffs Unnatural workflow Procedures or devices designed in an accident prone fashion 24 hour sleep deprivation was equal to a 0.1 blood alcohol level Error Reduction Strategies
Redundancy Forcing function Standard process checklist Decision aids and reminders Standardization Visual and Auditory Cues Thank you Discussion And Questions