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Human factors nhsiq 2014

The document discusses human error in healthcare, emphasizing that such errors are often a result of systemic failures rather than individual negligence. It outlines various factors contributing to errors, including personal and environmental conditions, and introduces models like Reason's accident causation model and the Swiss cheese model to illustrate how errors can occur. The importance of addressing human factors in system design to prevent, recognize, and mitigate errors is highlighted, along with strategies for improvement.

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Human Factors Overview•Patient Safety Insights•
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© NHS Improving Quality 2014 Human Factors: Human Error? To Err is Human – Planning for the human element in healthcare Patient Safety Team
© NHS Improving Quality 2014 The amazing colour changing card trick
© NHS Improving Quality 2014 If someone makes a mistake is it due to …………………. • Human Error? • Human Unreliability? • Human Performance Problem?
© NHS Improving Quality 2014 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)
© NHS Improving Quality 2014 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?
© NHS Improving Quality 2014 What is human error? “Human error is a failure of planned actions to achieve their desired ends” (Reason, 1990) PLAN PLANNING MISTAKES EXECUTION ERRORS ACTIONS OUTCOME
© NHS Improving Quality 2014 What is human error? It is an imbalance between • what the situation requires • what the person intends • what he/she does
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 Why do errors happen? • Simply put errors happen when multiple factors come together to allow them to happen • Human error = System error
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 Reason’s Accident Causation Model • Latent Conditions • Error producing conditions • Active failure • Defences
© NHS Improving Quality 2014 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 Leadership Rapid Response
© NHS Improving Quality 2014 Active Failure • Active failure – Occur at the level of the front line operator – Slips, lapses and mistakes – Violations (deliberately ignoring rules)
© NHS Improving Quality 2014 Error Producing Conditions • Error producing conditions – Environmental – Team – Individual – Task factors which effect performance
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 A smoke filled room
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 Defences
© NHS Improving Quality 2014 Human Factors Gear Box
© NHS Improving Quality 2014 Skills Rules Knowledge Framework (Rasmussen, 1983) Automatic Conscious Rule Based Knowledge Based Skill Based Unskilled or occasional user Novel 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
© NHS Improving Quality 2014 Conscious Control Mode Automatic Situation Routine Novel Problem Skill based Behaviour Rule based Behaviour Knowledge based Behaviour
© NHS Improving Quality 2014 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.
© NHS Improving Quality 2014 Human Error Taxonomy Human Failure Violations EXCEPTIONAL: Boundaries are changed in Order to full fill rush order Routine: Operator does not follow Because out of date Errors MISTAKESSLIPS KNOWLEDGE BASED A LACK OF EXPERTISE RULE BASED A failure of expertise e.g. Wrong diagnosis SKILL BASED Misapplied competence e.g. Operator fails to close one valve Due to confusion with another
© NHS Improving Quality 2014 Managing Human Error in Healthcare 1. Prevent Error 2. Recognise Error 3. Mitigate Error
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 Example The pharmacy porter whose job it is to deliver medicines to the wards injures their shoulder and is unable to work
© NHS Improving Quality 2014 Simple Analysis Pushing the trolley caused the injury
© NHS Improving Quality 2014 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)
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 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
© NHS Improving Quality 2014 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