human factors in healthcare dr nikki maran consultant anaesthetist, royal infirmary of edinburgh...
TRANSCRIPT
Human Factors in Healthcare
Dr Nikki Maran
Consultant Anaesthetist, Royal Infirmary of Edinburgh
Director, Scottish Clinical Simulation Centre,
Forth Valley Royal Hospital, Larbert
Human Factors...
• ‘...refers to environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work (in a way that can affect health and safety.)’
• Health and Safety Executive (1999)• Reducing Error and Influencing Behaviour
Basic Tenets of Human Factors
• Everyone makes mistakes
• Errors are often beyond our conscious control
Systems that depend on perfect human performance are fatally flawed.
The Human Factors Approach
Helps us understand why things don’t work right ….and find solutions!
The Human Factors Approach
Helps us understand why things don’t work right ….and find solutions!
• The task / technology (hardware / software)• The individual (liveware)• The organisation (environment)
The task / technology
Human Factors Solutions
• Ergonomics
• Improved Design
• Improved labelling / packaging
The individual
Why did Elaine die?
• Failure to intubate• Failure to oxygenate
Human Factors in Safety
AccidentCausation
Technical Factors
Human Factors
Organisational / SafetyCulture
OperatorBehaviour= +
(30-20%)
(70-80%)
Human Factors in Safety
AccidentCausation
Technical Factors
Human Factors
Organisational / SafetyCulture
OperatorBehaviour= +
(30-20%)
(70-80%)
Why did Elaine die?
• Failure to intubate• Failure to oxygenate
• Failure of leadership• Breakdown in decision making• Communication dried up• Lack of assertiveness• Loss of awareness
Why did Elaine die?
• Failure to intubate• Failure to oxygenate
• Failure of leadership• Breakdown in decision making• Communication dried up• Lack of assertiveness• Loss of awareness
Non-technical skills
Avoid problems
Identify & treatincidents
Manage emergencies
Health Committee patient safety report for NHS England (July, 2009)
“The NHS lags unacceptably behind other safety-critical industries, suchas aviation, in recognising the importance of effective team working and other non-technical skills.” (p5)
“There are serious deficiencies in the undergraduate medical curriculum .. which are detrimental to patient safety, in respect of training in ……non-technical skills....” (p6)
Human Factors Solutions
Identifying NTS in healthcare
Situation Awareness
Decision Making
Task Management
Team Working
Gathering Information
Recognising & Understanding
Anticipating
Anaesthetists’ Non-Technical Skills
Skill Categories
Skill Elements
Behavioural Markers
Good: keeps ahead of the situation by giving fluids / drugs Poor: is caught unaware by surgical actions
Human Factors Solutions
“The NHS must be able to provide the sort of simulation training that would make a difference to patients like Elaine Bromiley.”
CMO Annual Report 2008
The organisation
Systems Error
Everyday Examples
– Can put petrol in diesel tank
– Cars lurch forward when started in gear
Healthcare Examples– Patients admitted to wrong
wards due to bed shortages
– Legibility of handwritten orders (prescriptions)
• Allowing 100 mg to be administered if 10 mg was ordered
• Forcing functions • Redundancy• Simplification• Standardization • Automation and computerisation• Improve hand-overs• Improve access to information• Decrease reliance on memory
Human Factors Solutions
Effective Systems
From Reason
Error stopped,
no Accident occurs.
Develop systems and processes to prevent errors/accidents from happening and that
can manage them when/if they occur.
Moving Systems Towards Safety
• An unreported error/vulnerability cannot be investigated
If we don’t know about it, we can’t investigate it and we can’t fix it.
Barriers to Reporting
• Punitive culture
• Don’t know what to report
• Time
• Cumbersome reporting systems• Poor feed-back of reported events/actions
• Belief that “reporting doesn’t make any difference”
• Belief that “work-arounds” are the normal way of doing business
Learning from adverse events
• Identifying ‘near misses’– An error that occurs somewhere in the
process, but does not reach the patient– An error that has not turned into an
accident
• Could the recurrence of this event put another patient at risk in the future?
Incidents have been reported of air sucked in to the line from Y-ports of extension sets used with syringe pumps. Risk: air bubbles being pumped into the patient.The incidents have occurred with Wescott extension sets fitted with Y-ports.They have arisen since Wescott changed from a non-vented to a vented cap on the Y-port.
Potential problem recognised March 2010
Vented cap on Y-port.Air bubble in line
Incidents have been reported of air sucked in to the line from Y-ports of extension sets used with syringe pumps. Risk: air bubbles being pumped into the patient.The incidents have occurred with Wescott extension sets fitted with Y-ports.They have arisen since Wescott changed from a non-vented to a vented cap on the Y-port.
Potential problem recognised March 2010
July 2010PCA attached to central venous catheterPatient on CVVHAir entrained as aboveMassive air embolus results in dense hemiplegia
Vented cap on Y-port.Air bubble in line
Learning from adverse events
• Identifying ‘near misses’– An error that occurs somewhere in the
process, but does not reach the patient– An error that has not turned into an
accident
• Could the recurrence of this event put another patient at risk in the future?
• If so, DO SOMETHING TO RECTIFY
Changing the Culture
• Eliminate “shame and blame” mentality from healthcare
• Accept that our clinical staff will make errors and build systems to support their work
• Foster a culture of safety where people can speak up
• Organizational learning from errors and near-misses
The Human Factors Approach
Helps us understand why things don’t work right ….and find solutions!
• The task / technology (hardware / software)• The individual (liveware)• The organisation (environment)
www.chfg.org
www.institute.nhs.uk
www.iprc.abdn.ac.uk/ants
www.scsc.scot.nhs.uk