physician-patient interaction design: quality of service & error prevention

HVHF Sciences, LLC

Physician Interactions Medicine as a Sociotechnical

System

Moin Rahman Principal Scientist

HVHF Sciences, LLC

“Designing solutions when stakes are high, moments are fleeting and decisions are critical”

© HVHF SCIENCES LLC, ALL RIGHTS RESERVED 2011

Physician – Patient: Interactions


Medical Sociotechnical System



Physician – Patient

Professionals - support staff - specialists - …..

Technology - sensors - Displays - …..

Infrastructure - physical - virtual - …..

knowledge/skills

procedures

financial

regulations

…..


Safety

Effectiveness

Productivity

Well being

Goals & Challenges: Medical STS

Minimize errors,

Maximize successful outcomes

Cost effective


3 Topics

1) Workload

2) Cognition

3) System


Workload


Nurses

216 deaths nationwide from 2005 to the middle of 2010 in which

problems with monitor alarms occurred.”

ALARM FATIGUE

- Boston Globe

15-bed unit at Johns Hopkins Hospital:

- 942 alarms per day

- 1 critical alarm every 90 seconds


Yerkes-Dodson Law


Stress is a construct that refers to one’s response to an

imbalance between the expectations or demands placed on

individuals and the resources or capacities available to meet

them.

STRESS

MISMATCH: DEMAND vs. CAPACITY


Does nursing workload affect patient outcomes that are related to

patient safety?

- higher rates of non-fatal adverse outcomes

- higher incidence of medication errors.

WORKLOAD


(AHRQ

Physicians


- Interruptions: 6.6 times per hour

- 11 percent of all tasks were interrupted

- 3.3 percent of them more than once.

- Multitasking: 12.8 percent of the time

- did not return: 18.5 percent of the interrupted tasks

Source: Wesbrook et al.(2010)

Interrupt-driven Physician-

Patient Interaction

TASK TRUNCATION

INCREASE IN TASK-on-TIME


Cognitive Load vs. Task Time


1. Filtering

2. Memory management

3. Task switching (impaired)

The Myth of

Multitasking


Sterile cockpit – below 10,000 feet…

Critical Interactions

“sterile”


Cognition

Detection & Diagnosis


Sherlock Holmes


Dr. House


Jig Saw Puzzle



(Endsley)

Clinical Puzzle


Clinical Puzzle

Missed diagnosis (rate of error): 15%

Clinical Dignosis

Man stands in contrast with man-made systems


(Elstein, 1995)

Overdiagnosis

Predictable trajectory…(swiss cheese model)

Challenges and Errors: error begets error

http://www.sciencedirect.com/science/article/pii/S0010027711001995

American airlines crash Cali…

Heuristics – short cuts – Recognition Primed Decision Making: Fire Fighters

Heuristics & Biases




Heuristic

Heuristic is a mental shortcut – a rule of thumb -- because the underlying shortcut is typically correct and produces the desired result in most cases with minimum cost, delay, and anxiety.

Heuristics & Biases

Bias

A prejudice, partiality, preconception, conjecture, or prejudgment that leads to misinterpretation.


Thin slicing

Questioning style

Affective connection

Social Interaction


Heuristics


Ratio of words that start with R (“red”) vs. words that R in the third position (“car”)

1:2

Availability Heuristic

Anchoring Heuristic

Premature closure

Heuristics


Overdiagnosis

Predictable trajectory…(swiss cheese model)

Challenges and Errors: error begets error


American airlines crash Cali…

Heuristics – short cuts – Recognition Primed Decision Making: Fire Fighters

Heuristics & Biases




Attribution errors

Affective error

Confirmation bias

Blindness bias

Unaware what we don’t know.

Physician Cognitive Errors (biases)


Blindness Bias

God grant me the serenity

to accept the things I cannot change;

courage to change the things I can;

and wisdom to know the difference.

- Reinhold Niehbur


Serenity Prayer

Blindness Bias

To know that one knows what one knows,

and to know that one doesn't know what one

doesn't know,

there lies true wisdom.

- Confucius


Diagnostician’s Serenity Prayer

Lung Cancer: Surgery or Radiation?

MORTALITY FRAME

10% chance of dying (“dying frame”) 90% chance of survival (“survival frame”)

Surgery Election 58% (“dying frame”) 75% (“survival frame”)

Framing


Citizens

e.g. health insurance

Public Policy Makers

e.g., homeland security vs. healthcare

Loss Aversion



High Stakes in Decision Making

HVHF Sciences, LLC

41

Nonequilibrium Events Volatile

Uncertain

Complex

Ambiguous

Time

“Golden Hour”

42

“Emergency or crisis conditions occur suddenly and often unexpectedly,

operators must make critical decisions under extreme stress, and the

consequences of poor performance are immediate and catastrophic.”

(Salas, Driskell & Hughes, 1996).

Nonequilibrium: Human-Machine Systems


Snake in the Grass Effect

System Interactions


Conventional Wisdom:

Errors were the fault of the person committing

them.

- not the machines they operated

- the procedures that they were given

- the environment in which they worked

Errors: Who is to Blame?


44,000 - 98,000 Americans die

from medical errors/year

To Err is Human (IOM, 1999)


"Simply put: humans design, manufacture, train,

operate, manage and defend the system. Therefore,

when the system breaks down, it is of necessity due to

human error somewhere. From this perspective and

depending upon the level of observation, one hundred

per cent of accidents are arguably caused by human

error.“

- ICAO Safety Management Manual (doc. 9859, para. 7.10.6)

The “genesis” of Error


(Woods, et al.)

A Tale of Two-Ends



Swiss Cheese Model (James Reason)


(Cooks, Woods & Miller)

How were the defenses breached?


Hindsight Bias


Unsafe Acts

Unintended Action

intended Action

Slip

Lapse

Mistake

Violation

Attentional Failures

Memory Failures

Rule-based mistakes

Knowledge-based mistakes Failures

Routine/Exceptional violations

Sabotage

Taxonomy of Error (James Reason)


Swiss Cheese Model (James Reason)


Cultural

Dimension High Low

Power distance + _

Individuality Individualistic Collective

Toughness Masculine Feminine

Uncertainty

avoidance Reliability Novelty

Long-term

orientation

Long term

investments Short term resullts

(Hofstede)

3 Topics

1) Workload

2) Cognition

3) Systems



Physician – Patient

Professionals - support staff - specialists - …..

Technology - sensors - Displays - …..

Infrastructure - physical - virtual - …..

knowledge/skills

procedures

financial

regulations

…..



3 Topics

1) Workload

2) Cognition

3) Systems

physician-patient interaction design: quality of service & error prevention

Healthcare