Human factors nhsiq 2014

© NHS Improving Quality 2014

Human Factors: Human Error?

To Err is Human – Planning for the human element in healthcare

Patient Safety Team


The amazing colour changing card trick


If someone makes a mistake is it due to ………………….

• Human Error?

• Human Unreliability?

• Human Performance Problem?


Human Error

“We cannot change the human condition but we can change the conditions under which humans work.”(Reason, 2000)

“Blaming individuals is emotionally more satisfying than targeting institutions.” (Reason, 2000)

“Human error is the failure of desired actions to achieve their desired ends.” (Reason, 1990)


Planning for the human element in healthcare

• Why were medicines given to the wrong patient?• Why was the needle recapped before disposal?• Why lift manually when a ceiling lift was available?• Why weren’t gloves and a mask worn?• Why was the patient agitation/pain not noticed?


What is human error?

“Human error is a failure of planned actions to achieve their desired ends” (Reason, 1990)

PLAN

PLANNINGMISTAKES

EXECUTIONERRORS

ACTIONS OUTCOME


What is human error?

It is an imbalance between

• what the situation requires • what the person intends• what he/she does


Human error happens when…

• Plan to the right thing but with the wrong outcome

• Do the wrong thing for the situation

• Fail to do anything when action is required


Why do errors happen?

• Simply put errors happen when multiple factors come together to allow them to happen

• Human error = System error


Human Factors Issues • Errors are the result of a system as a whole

• Context is everything

• No longer about – Naming– Blaming– Shaming– Retraining

• Isolate errors from context and human factors has little or no remedial value


Why is this important?

Example: Medication Error

Primary Consequence: Patient’s Health

Other Consequences: • Increased workload for patient care• Stress, anxiety, guilt for health care professionals• Stress for supervisors and managers• Financial consequence for the organisation


The system model (Reason 2006)

• Fallibility is part of the human condition• Adverse events are the product of latent

pathogens within the system• Sharp enders are more likely to be the

inheritors than the instigators• Remedial effort is directed at improving

differences and removing error traps• Need safety culture to motivate personal

responsibility to prevent errors


Reason’s Accident Causation Model

• Latent Conditions

• Error producing conditions

• Active failure

• Defences


The Swiss cheese model of how defences, barriers, and safeguards may be penetrated by an accident trajectory.

Reason J BMJ 2000;320:768-770

©2000 by British Medical Journal Publishing Group

Mitigation

Recognition

Prevention

Policy

LeadershipRapid

Response


Active Failure

• Active failure– Occur at the level of the front line operator– Slips, lapses and mistakes– Violations (deliberately ignoring rules)


Error Producing Conditions

• Error producing conditions– Environmental– Team– Individual– Task factors which effect performance


Personal & environmental factors

• Personal Factors• Fatigue• Lack of sleep• Illness• Irregular work patterns• Drugs or alcohol• Boredom• Frustration• Fear • Shift work• Reliance on memory• Reliance on vigilance

• Environmental Factors• Distractions

– Noise– Heat– Clutter– Motion– Lighting

• Too many handovers– Unnatural workflow

• Poorly designed procedures or devices

• Inadequate training and skills

Heather Shearer

separate into two columns more clearlyclear what highlighted and why


A smoke filled room


Latent Conditions

• Tend to be removed from the direct control of the operator

• Poor design • Incorrect installation• Faulty maintenance• Bad management decisions• Poorly structured organisations


Defences


Human Factors Gear Box


Skills Rules Knowledge Framework (Rasmussen, 1983)

Automatic

Conscious

Rule Based

Knowledge Based

Skill Based

Unskilled or occasional userNovel environment

Pre-packaged behaviour e.g. if the symptom is X then the problem is Y, OR if the problem is Y do Z

Automated and requires little conscious attention


Conscious

Control Mode

AutomaticSituation

Routine

Novel Problem

Skill basedBehaviour

Rule basedBehaviour

Knowledgebased

Behaviour


Slips and Mistakes

• Slips– Intention is correct but a failure occruing when

carrying out the activity required

• Mistake– Incorrect intention which leads to an incorrect

action sequence. These usually occur due to lack of knowledge.


Human Error TaxonomyHuman Failure

Violations

EXCEPTIONAL:Boundaries are changed inOrder to full fill rush order

Routine:Operator does not follow

Because out of date

Errors

MISTAKESSLIPS

KNOWLEDGE BASEDA LACK OF EXPERTISE

RULE BASEDA failure of expertise e.g.

Wrong diagnosis

SKILL BASEDMisapplied competence e.g.

Operator fails to close one valve Due to confusion with another


Managing Human Error in Healthcare

1. Prevent Error2. Recognise Error3. Mitigate Error


Use Human Factors Knowledge to design systems

• Standardise the work environment• Select equipment with safety features• Provide backup for critical personnel and

equipment• Provide clear supervision and direction


Example

The pharmacy porter whose job it is to deliver medicines to the wards injures their shoulder and is unable to work


Simple Analysis

Pushing the trolley caused the injury


Human Factors Analysis

• The porter had had a sore shoulder for many weeks but had failed to report his symptoms because they could still work (error in early reporting and porter training)

• The trolley was old and didn’t run in a straight line because the wheels were wonky. (error in policy and maintenance)

• The trolley was too tall to see over when full; therefore full trolleys were pulled instead of pushed. (error in purchasing and job design)


Exercise

• Discuss the last error that you were involved in / analysed and consider this from a human factors perspective.

• How does the theory apply to this?• Knowledge• Skill• Behavioural errors


Human Error Type

Typical Forms Common Prevention Strategies

Slip / Lapse • Double capture• Omission• Interference• Perpetual

Confusion

• Minimising Interruptions• Forcing Functions• Colour coding, highlighting

differences• Checklists, memory aids

Rule Based Mistake

• Strong but wrong• Exception to rule• Cognitive Overload

• Minimise / highlight exceptions

• Provide feedback• Manage workload

Knowledge based mistake

• Confirmation bias• Out of sight, out of

mind

• Decision support• Team work

Summary


Exercise• Look at your process and consider how you

will include Human Factors in your design.

• Think about how you will observe your process through fresh eyes.

Insert date/time


How it fits

• Now is the time to use your safety improvement knowledge:

• Human Factors• Model for Improvement• PDSA and small tests of change• Metrics and measurement for Improvement• Engagement• Spread and adoption• Sustainability

Human factors nhsiq 2014

Healthcare

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