ME Forum 2019 Orientation & Human Factors Into Improvement - - PowerPoint PPT Presentation
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
Integrating Safety Science & 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
attendance per session, requiring delegates to attend a minimum of 80% of a session to qualify for the allocated CPD hours.
hours 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.
Cognitive Science
(how we think)
Industrial and Organizational Psychology
(how we collaborate)
System Safety Engineering
(how we manage risk)
Work Analysis
(how we work now)
…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.
“We don’t redesign humans; We redesign the system within which humans work”
www.MedicalHumanFactors.net
Knowledge-Based Rule-Based Skill-Based
Improvisation in unfamiliar environments No routines or rules available Protocolized behavior Process, Procedure 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)
– Initial ED values = hyperglycemia – “I know my sugars, and I’m not low” – Ate all meals, snacks
– Due to fixation effect and expectations – Glucometer design plays into this failure to revise – Actions taken initially have no effect
Within Reportable Range Critical High Critical Low
(… making the RN ‘see’ a critical high)
(… on the ‘garden path’ story of hyperglycemia)
(… that hypoglycemia is a ‘never’ event on unit)
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
https://www.youtube.com/watch?v=zeldVu-3DpM
Testimony to congress
Reckless Behavior
Conscious disregard of unreasonable risk Manage through:
At-Risk Behavior
A choice: risk not recognized or believed justified Manage through:
Risk Behaviors
healthy behaviors
awareness
Normal Error
Inadvertent action: slip, lapse, mistake Manage through changes in:
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)
The Three Behaviors
– Product labeling – Product packaging
– Mix for drip only vs bolus only = SAME vial!
– Skills based error – automaticity, expectation – Lack of cues for recovery
Ref: J. Jorgenson, ASHP Leadership Forum 2010
$$$$
– (excluding bounces)
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.
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Inattentional Blindness
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Task Fixation
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Satisfaction of Search
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Our Current Solution: “don’t let go of the wire…” “Always check the whole XR”
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Will we achieve high reliability?
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System Solutions?
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Computer aided diagnosis?
Healthcare: Complex adaptive system Humans and Technology “Sociotechnical System”
Ordered & Constrained
& Can be reduced to a set of rules
Unordered: Cannot predict cause & Effect
& Cannot be modeled or forecasted
“Adaptive” in that their individual and collective behavior changes as a result of experience
How managers believe work is being done (rules)
Every-day work: How work IS being done
Adapted from: Ivan Pupulidy
User Interface Design Displays and Controls Screen Design Clicks & Drags
Cognitive Task Support “Workflow Design” Data Visualization Functionality User Experience (UX Design)
www.MedicalHumanFactors.net
– Developed and used by humans to support their
cognitive work
www.MedicalHumanFactors.net
nextgen
www.MedicalHumanFactors.net
Audit: 50% Compliance with Hospital VTE guideline…
Multiple inpatient PEs
Fairbanks RJ, Caplan S, Panzer R. Proceedings of HCI-International 2005, July 2005.
IFF changes feasible in context of work
Thomadsen, Lin. Advances in Patient Safety: Vol. 2, AHRQ 2008
www.MedicalHumanFactors.net
Knowledge-Based Rule-Based Skill-Based
Improvisation in unfamiliar environments No routines or rules available Protocolized behavior Process, Procedure 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
www.MedicalHumanFactors.net
1.
Focus on organizational accountability
2.
Learn from hazards, 1o and 2o prevention
3.
Integrate sustainable, effective solutions
4.
Create solutions appropriate for error type
5.
Create solutions based on work as performed
6.
Base response on risk (not outcome)
7.
Optimize Processes & Support Work
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