Integrating Safety Science ME Forum 2019 Orientation & Human Factors Into Improvement Rollin J “Terry” Fairbanks, MD MS CPPS Founding Director, National Center for Human Factors in Healthcare Professor of Emergency Medicine, Georgetown University Vice President, Quality & Safety, MedStar Health, USA
As part of our extensive program and with CPD hours awarded based on actual time spent learning, credit hours are offered based on attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours. • Less than 80% attendance per session = 0 CPD hours • 80% or higher attendance per session = full allotted CPD hours ME Forum 2019 Orientation Total CPD hours for the forum are awarded based on the sum of CPD hours earned from all individual sessions. Conflict of Interest The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation.
Conflict of Interest The speaker(s) or presenter(s) in this session has/have no conflict of interest or disclosure in relation to this presentation. ME Forum 2019 Orientation
Goal Think Differently…. To view safety and risk through the lens of safety science
Cognitive Industrial and Science Organizational (how we think) Psychology (how we collaborate) Work Analysis System Safety (how we work now) Engineering (how we manage risk)
Human Factors Engineering …discovers and applies scientific data about human behavior & cognition, abilities & limitations, physical traits, and other characteristics …to the design of tools & machines, systems, environments, processes, and jobs for productive, safe , comfortable , and effective human use.
Human Factors Engineering “We don’t redesign humans; We redesign the system within which humans work”
Knowledge-Based Improvisation in unfamiliar environments No routines or rules available Rule-Based Protocolized behavior Process, Procedure Skill-Based Automated Routines Require little conscious attention Figure adapted from: Embrey D. Understanding Human Behaviour and Error, Human Reliability Associates Based on Rasmussen’s SRK Model of cognitive control, adapted to explain error by Reason (1990, 2008) www.MedicalHumanFactors.net
Slips and Lapses: Common Policies, Inservices, Discipline, Training, Vigilance, “Mindfulness”
How could you miss it?
The ‘Second Story’ • Patient has multiple signs of normal-high BG – Initial ED values = hyperglycemia – “I know my sugars, and I’m not low” – Ate all meals, snacks • There was an ongoing failure to revise – Due to fixation effect and expectations – Glucometer design plays into this failure to revise – Actions taken initially have no effect • ‘Fresh’ personnel discover true problem
“Critical Low” 0.1% (119/80,000) Within Reportable Range Critical High Critical Low
Failure to Revise Priming (… making the RN ‘see’ a critical high) + Fixation (… on the ‘garden path’ story of hyperglycemia) + Expectation (… that hypoglycemia is a ‘never’ event on unit) = A perfect set-up for a ‘failure to revise’ error
6 Hospitals Hospital Text of ‘Out of Reportable Range’ message popup 1 Critical value; Repeat; Lab Draw for > 600. 2 RR Lo = result <40; RR Hi = result >600 3 Out of range: repeat test to confirm 4 Critical value; repeat within 15 mins; notification required; lab draw for >600 5 Critical value; you must repeat immediately; STAT glucose Lab draw for RR HI 6 Repeat test
Repeated Incident • Same scenario • Multiple RNs, NP involved • All misinterpreted critical LO as critical HI THIS WAS A NORMAL ERROR
What is the impact on the safety culture? (Annie’s story) https://www.youtube.com/watch?v=zeldVu-3DpM
Safety Attitudes “ The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” --Dr. Lucian Leape; Professor, Harvard School of Public Health Testimony to congress
Just Culture: The Three Behaviors Normal At-Risk Reckless Error Behavior Behavior A choice: risk not recognized or Conscious disregard of Inadvertent action: slip, lapse, believed justified unreasonable risk mistake Manage through changes in: Manage through: Manage through: • Processes • Removing incentives for At- • Remedial action • Procedures • Punitive action Risk Behaviors • Recurrent training • Creating incentives for • Design healthy behaviors • Environment • Increasing situational awareness • Re-examining environment Support Coach Sanction Adapted from: David Marx, Just Culture. Outcome Engineering 2008: www.JustCulture.org Alternative Perspective: Just Culture: Balancing Safety and Accountability, Sidney Dekker (2008)
Heparin Case • Human Factors Issues – Product labeling – Product packaging – Mix for drip only vs bolus only = SAME vial! – Skills based error – automaticity, expectation – Lack of cues for recovery • RCA also focused on 5 rights Ref: J. Jorgenson, ASHP Leadership Forum 2010
$$$$
At the skill-based level, humans see patterns • Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoetnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe.
“Wire Case”
Cognitive Tasks Basketball Video Instructions: • Follow white shirts carefully • Count passes – (excluding bounces)
Cognitive Tasks Inattentional Blindness n Task Fixation n Satisfaction of Search n Our Current Solution: n “don’t let go of the wire…” “Always check the whole XR” Will we achieve high reliability? n System Solutions? n Computer aided diagnosis? n Lum, Fairbanks, et al. Misplaced Femoral Line Guidewire and Multiple Failures to Detect Foreign Body on Chest X-ray. Acad Emerg Med, 2005; 12(7): 658-662.
Healthcare: Complex adaptive system Humans and Technology “Sociotechnical System” Unordered: Cannot predict Ordered & cause & Effect Constrained & & Cannot be Can be modeled or reduced to a forecasted set of rules “Adaptive” in that their individual and collective behavior changes as a result of experience 1. Sardone G, Wong G, Making sense of safety: a complexity based approach to safety interventions. Proceedings of the Association of Canadian Ergonomists 41st Annual Conference, Kelowna, BC, October 2010 2. Snowden D, cognitive-edge.com 3. Hollnagel, Woods, Leveson 2006
Complex Adaptive Systems: work as done –vs- work as imagined How managers believe work is being done (rules) GAP Every-day work: How work IS being done Adapted from: Ivan Pupulidy
The Two Bins of Usability User Experience (UX Design) User Interface Design Cognitive Task Support Displays and Controls “Workflow Design” Screen Design Data Visualization Clicks & Drags Functionality
www.MedicalHumanFactors.net
Cognitive Psychology • Cognitive Artifacts: – Developed and used by humans to support their cognitive work
nextgen www.MedicalHumanFactors.net
www.MedicalHumanFactors.net
Example… % 6 Multiple inpatient PEs 6 à occur over 2 years % 0 5 Audit: 50% Compliance with Hospital VTE guideline…
CPOE Pathway: Screen #1
CPOE Pathway: Screen #2
CPOE Pathway: Screen #3
Result of CPOE Pathway • Readily accepted by providers • Increase in appropriate prophylaxis rates 50% à 66% à 93% Fairbanks RJ, Caplan S, Panzer R. Proceedings of HCI-International 2005, July 2005.
Hierarchy of Solutions IFF changes feasible in context of work 1. Fix environmental problems 2. Forcing functions and constraints 3. Automation and computerization 4. Protocols, standards, information, alarm 5. Independent verification/redundancy 6. Rules and policies 7. Education, training, instruction Thomadsen, Lin. Advances in Patient Safety: Vol. 2, AHRQ 2008
“Fallibility is part of the human condition; We cannot change the human condition; But we can change the conditions under which people work” --James Reason, PhD
Knowledge-Based Improvisation in unfamiliar environments No routines or rules available Rule-Based Protocolized behavior Process, Procedure Skill-Based Automated Routines Require little conscious attention Figure adapted from: Embrey D. Understanding Human Behaviour and Error, Human Reliability Associates Based on Rasmussen’s SRK Model of cognitive control, adapted to explain error by Reason (1990, 2008) www.MedicalHumanFactors.net
Slips and Lapses: Common Policies, Inservices, Discipline, Training, Vigilance www.MedicalHumanFactors.net
Recommend
More recommend
