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Human Factors Engineering in Healthcare systems:the problem of human error and accident management
Pietro Carlo Cacciabue
EC, Joint Research CentreInstitute for the Protection and Security of the Citizen
Ispra, (VA), Italy
HUMAN FACTORS & MEDICAL INFORMATICS Lille, France, 22 - 24 May 2006
Estimated error risk: USA
• Between 44,000-98,000 patients die as the result of medical errors.
• In 1993, fatalities due to medication errors (7,000) exceeded workplace accidents (6,000).
• Errors by healthcare workers affect approx. 3-4% of patients.
• The cost associated with medical errors is around $29 billion annually.
Comparative rates*
• In US, patient experiences 2 errors a day on average.
• This equates to:– 2 bad landings a day at O’Hare– 32,000 cheques hourly from wrong account
• In US, more people die in horse-drawn vehicles than commercial aircraft.
* British Medical Journal
Annual error risk: UK
• 400 deaths involving medical devices.• 10,000 experiencing adverse drug effects.• 1,150 psychiatric patients commit suicide.• 28,000 written complaints.• £400 million paid out for negligence claims.• Harm occurs in around 10% of admissions.• These cost NHS £2 billion a year in additional
hospital stays.
Is health care unusually fallible? NO
• Patients are more at risk than non-patients.• Medical interventions are, by their nature,
high-risk procedures—small error margins.• Medicine remains an inexact, hands-on
endeavour. Errors are inevitable.• Doctors and patients collude in disguising
the incompleteness of medical knowledge.
But even if . . .
• Healthcare professionals knew all there was to know, they would still make errors.
• Like the rest of human kind, they are fallible.
• But the fact that they are not trained to understand, accept and manage their fallibility lies at the heart of the medical error problem.
Learning to live with error
• Recognise that fallibility is the norm• Errors do not inevitably lead to mishaps• Errors are consequences as well as causes• Naming, blaming and shaming have no
remedial value• Design healthcare systems for real human
beings—warts and all.
Three error types*
• Errors happen when . . .– You know what you’re doing, but the actions
don’t go as planned (slips, lapses, fumbles)– You think you know what you’re doing, but
fail to notice contra-indications, apply a bad ‘rule’ or fail to apply a good ‘rule’ (mistakes and/or violations)
– You’re not really sure what you’re doing (mistakes in novel situations)
* Reason, J. (1997). Managing the risks of organisational accidents. Ashgate, Aldershot, UK.
Two ways of looking at the human contribution
• The PERSON approach: Focuses on the errors and violations of individuals. Remedial efforts directed at people at the ‘sharp end’.
• The SYSTEM approach: Traces the causal factors back into the system as a whole. Remedial efforts directed at situations and organizations.
The ‘Swiss cheese’ modelof accident causation*
Some holes dueto active failures
Other holes due tolatent conditions
(resident ‘pathogens’)Successive layers of defences, barriers, & safeguards
Hazards
Losses
*Ref. J. Reason
Error rates in aviationDerived from observing error rates in 44 flight
hours.
100,000,000+ errors per year
1000 official incident files
100 major incidents
25 accidents
Event rates in surgeryEvents largely due to errors
• Based on direct observation of 165 arterial switch operations: 21 surgeons, 16 centres.
• Average rate: 7 events per procedure– 1 major event (life-threatening)– 6 minor events (disrupts flow, irritates)
• Over half of the major events were successfully compensated: 20% for minors.
• Best compensators get the best outcomes.
A typical major event scenario
Cardiologistmisdiagnoses
coronary arterypattern
Surgeon has not metthis pattern before
Other membersof team are
equallyinexperienced
Surgeon performs aninappropriate procedure
But that is not the end of the story
The surgeon and the team canstill recover the situation
COPINGRESOURCES
Limited coping resourcescan get nibbled away
Accumulation of minor events. Not so much
holes as steadyattrition
Summarising findings• The frequency of events during a procedure
has a profound effect upon outcome.• Compensating major events eliminates any
increased risk of death.• Good compensators have good outcomes• Compensation for minor events is far less
important than their total number.• Minor events erode the coping abilities of
the surgical team.
Managing the manageable
• Fallibility is part of the human condition.
• We are not going to change the human condition.
• But we can change the conditions under which people work.
Engineering Approach to deal with Human Errors
• What is done in other domain• Compare working contexts and techniques• Apply same safety concepts• Need to adapt generic approach to specific
contexts• Data collection, Recurrent Safety Audits• Management with high safety culture
Is it possible that a community of persons• Highly qualified• Motivated• KnowledgeableMake errors that are banal or not explicable
Is it possible• Prevent errors• Recuperate from errors • Mitigate consequences
AviationMedicineNuclearProcess IndustryRail and Road Transport …….
Event
Context and working environment
Human Factors Pathway System Factors Pathway
Defenses, Barriers, Safeguards
Contextual Factors(external)
Casual factors(random)
Active Errors System Failures
Organisational Processes
Latent Errors
Training, Procedures, …… Protection, Emergency, Safety Systems ……
Personal Factors(internal)
Failure of Defenses,Barriers, Safeguards
Generic Framework for
Accident Studies
MEDICINE e AVIATION:Very distant domains, but Many commonalities with respect to human and
organisational issues
Fundamental commonality: Different realties that collaborate to a common objective
Aviation: Cockpit, Maintenance, ATC, Cabin crew, …
Medicine: Operating Theatre (OT), Wards, Laboratories,..
Cabin vs. Operating TheatreOT and Cockpit Similar models of processes and functions Strong safety culture of pilots and surgeons (± safety) Plenty of organisational factorsBuild of different realities
Cockpit Integrated instruments/systemsTransport of persons/goods Small Teams with clear rules
and procedures
OTDifferent instrumentsOne single patient Very complex teams with
discipline/diverse culture
But
Is it possible to prevent human Errors, recover and protect/mitigate consequences
Performance Indicators
Analysis of rules, procedures, needs Ethnographic studies Data collection and analysis
Events – HE in Aviation
ASRS :Aviation Safety Reporting System
100,000,000+ errors per year
1000 official incident files
100 major incidents
25 accidents
Events – HE in Medicine
* Workshop on Assembling the Scientific basis for Progress on Patient Safety ( AMA, Chicago, 1998)
Incidents* Errors Discipline Consequences
Florida (amputation) Wrong leg amputation Licence Removed
Betsy Lehman Overdose of Chemotherapy Management removed
Gargano Overdose of Chemotherapy Management removed
Ben Kolb Aesthetic Exchange Police investigation
Libby Zion Exchange of medication Revision of shifts
Einaugler Erroneous injection Doctor arrested
Colorado Exchange of medication Police investigation
* R. L. Helmreich & A. Merri. Culture at work in aviation and medicine. Ashgate, Aldershot, UK (1998).
Errors in OT* Consequences on patient
Lack of communication between surgeon-anaesthesiologist loss of patient
Missing checklist on anaesthesia machine serious problems
Misuse of Oxygen machine serious problems
Surgeon distracted by other operation serious problems
Missed come round of patient ………..
Lack of leadership
Lack of exchange of information on patient characteristics
Conflict of personalities during operation
Inadequate briefing between doctors
………………..
Comparison Medicine - Aviation
In medicine error events seem more frequent than in aviation.
Great variety of involved experts Great number of barriers Errors more frequently identified and
mitigated by system
Six Crucial Requisites for data collection and analysis
Learning
Independence
Interdisciplinary
No blame culture
Minor incidents
Specific analysis