Human Factors and Patient Safety

Frank Federico, RPh

8 October 2015This presenter has nothing to disclose.

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 Error4

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

Human Factors

physical demands,

skill demands,

mental workload,

and

other such factors

adequate lighting,

limited noise, or other

distractions

device design, and

team dynamics

Human Factors Engineering: Examines a particular

activity in terms of its component tasks and then

considers each task in terms of:

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

6

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

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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

Changes:

– Training and education on 6 rights

– Font on medication label increased.

Did this solve the problem?

Case

Parenteral solutions administered via wrong

route

Changes

– Training and education

– Labels on tubing

– Be more vigilant

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

What did the proposed changes miss?

http://homepage.mac.com/lesposen/iblog/B80495344/C840540124/E1966059962/

Poor Design

Interruptions

Overconfidence

Fatigue

FAILURES

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

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

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.

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Human Factors Violations:

Drivers of Human ErrorFatigue

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

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

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

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).

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.

Reliance on Memory

Working memory is limited, and when attention is drawn

elsewhere, it can be especially vulnerable

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?

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

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

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.

Error Reduction Overview: Hierarchy of

Controls

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Standardization & Simplification

Policies,

Training,

Inspection

Minimize consequences

of errors

Make it easy to do

the right thing

Make it hard to do the wrong thing

Eliminate the opportunity for error

Human

Factors

Mitigate

Facilitate

Eliminate

Make errors visible

Doug Bonacum

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

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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.

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

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.

Anesthesia

Mix up of gases

Changed connectors for different gases

Mix up of gases no longer a problem.

Tubing Connections

Figure 1. Tube delivering

oxygen fell off nebulizerFigure 2. The oxygen tubing was connected

to a Baxter Clearlink needleless port.

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.

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

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.

The Case of Nifedipine Gel

Simplicity of Design

Use Visual Controls 49

Stove A

Stove B

Which dial turns on the burner?

50

51

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Computerized drug-drug interaction

checking

– Drug information databases

– Customized drug rules

Preprinted orders

– Chemotherapy order form

– Pain management order forms

Avoid Reliance on Memory

53

Formulary restrictions

– Remove items

– Eliminate therapeutic duplications

– Limit availability

Heparin weight based protocol

– Simplifies ordering process

– Provides comprehensive orders

Simplify

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%

55

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

Standardize

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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

Use Protocols and Checklists

57

Include “Indication” with orders/prescriptions

Drug information sources

– Determine ease of use

Location of medication list/problem list

Improve Access to Information

58

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

Reduce Handovers

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Strategy: Avoid Look-alike/Sound-alike

Drug Names

Display lists of easily confused drug namesHow 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

60

Errors multiply if input is incorrect

Automated dispensing machines

Computerized physician order entry

Automate Carefully

61

Reduce Interruptions and Distractions

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)

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

64

Habits and Patterns (Continued)

Patient medication

list

– Sleeve to hold

insurance

card and

medication list

Hand Hygiene

Using a nudge instead of a ruleNudge 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).

65

Promote Effective Team Functioning

66

Listening Exercise

67

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 robber 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

68

Technology

69

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…..

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?

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

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 ‘use-

by’ date.

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

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)

Socio-technical Aspect

The socio-technical nature of IT means that the

technology and the context within which it is used

cannot be separated

The Impact of the Automated Automobile

The Monk and the Help Desk

“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

Tendency to underestimate the

complexity embedded in paper

Alarm-related Deaths

According to The Joint Commission, there were 80

alarm-related deaths in the U.S. between January

2009 and June 2012.

http://psqh.com/alarm-fatigue-hazards-the-sirens-are-calling

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.”

“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.http://www.boston.com/bostonglobe/editorial_opinion/letters/articles/2010/02/28/hospitals_dont

_turn_up_the_volume_lower_the_noise/

SoundEar

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

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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?

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

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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

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

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

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VA National Patient Safety Center

http://www.patientsafety.va.gov/professionals/onthejob/cognitive.asp

“We can’t change the human

condition, but we can change

the conditions under which

humans work.”

James Reason

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Take a moment to reflect

on your own work.

What will you incorporate from

this session into your plans?