WHAT CAN HUMAN FACTORS OFFER PATIENT SAFETY?

1. WHAT CAN HUMAN FACTORS OFFER PATIENT SAFETY? Shelly Jeffcott, PhD Monash University shelly.jeffcott@med.monash.edu.au

2. Talk Overview (1) Human factors • Multiple definitions and disciplines • Objectives • Healthcare example (2) Patient safety • Progress so far • Healthcare vs. Other Industries (3) Integration • Opportunities • Challenges (4) New approach (“Resilience”) • Focus on what builds safety rather than what degrades it

3. People Tools (1) HUMAN FACTORS • “BUZZWORD”… Human factors is the study of interrelationships between: • (i) people • (ii) the tools they use, and, • (iii) the environments in which they live and work Environment

4. Definition • Different words… Human factors integration Human factors engineering Human factors psychology

5. Multidisciplinary Psychology Comp Science Engineering HUMAN FACTORS Education Ergonomics Anthropology

6. Objectives “The overall goal of human factors is to optimize the relationship between humans and systems with which they interact to reduce error and failure and so improve safety.” • 5 SUB-CATEGORIES: • Performance enhancement • Resource conservation • Acceptance • Cost reduction • Safety!!!

7. HC Example • Obstetric Adverse Event “A woman arrives at a hospital to give birth. She has a strep infection and is prescribed penicillin to be delivered by IV to prevent the infection from spreading to the baby. She also asks for an epidural for pain control. The nurse retrieves the epidural bag and sets it on the counter next to the patient. Soon after, the penicillin bag arrives and is set down next to the epidural bag. The nurse prepares to administer the penicillin and accidentally takes the wrong bag, administering the epidural analgesic (intended for injection into the spine) into the patient's bloodstream. Soon after the patient goes into a seizure and dies later that evening”

8. What happened? • Was the nurse fatigued as a result of taking on an extra shift? • Was she distracted by tasks relating to one of five other patients under her care? • Was she expected to remember too much information at one time? • Was it because the two tasks were so similar that she became confused? • Was it because the labeling on the two IV bags was easily mixed up?

9. Why did it happen? • Shift rotation • Short-term memory demands • Task patterns • Distraction • Poorly designed medication packaging * These human factors that shape how well humans perform in the workplace and knowledge of such factors can be used to prevent errors Healthcare professionals need to gain basic understanding of human factors & how they relate to medical mishaps

10. (2) PATIENT SAFETY • Patient safety should address the need to identify: • Current practices that impede quality care • Why health professionals and patients do what they do • How systems approaches can be used to implement change 2005, Leape & Berwick, JAMA Special Commentary 2008, Grol, Berwick & Wensing, BMJ Analysis

11. Key lessons • Preventable medical errors are a serious problem • Reporting systems show the tip of the iceberg • Bad systems not bad people lead to majority of errors • Clear systems of accountability without blame • Technology can help support safer care if designed around actual work processes • Partnerships among policy makers, managers, clinicians and researchers are necessary

12. Other industries • The Federal Aviation Administration has a human factors research and engineering division • US Nuclear Regulatory Commission has a human factors program that grew out of the Three Mile Island incident • The US Food and Drug Administration has made a commitment to ensuring the application of human factors engineering • These other high risk industries have shown reduced error rates and improved safety when following human factors approaches

13. Key barriers • “Although decades of research in other high-risk organizations have clearly demonstrated success this is highly dependent on organizational factors such as leadership support, learning climate, and commitment to data-driven change” (Salas et al. 2009). • What are we up against in HC? • “Hypercomplex” cf. other high-risk domains • Resistance to change among health professionals • Fragmentation and diffuse accountability • Organisational structures that block improvement • Dysfunctional (financial) incentives

14. In summary… • What we need? Shared vision Common purpose Team working Responsibility Leadership NTS Training (Qualitative) • What we have? • Fragmentation • Individualism • Hierarchy • Blame • Accountability • Technical • (Quantitative) Can HF help us?!

15. (3) INTEGRATION • But additional challenges… • Lack of awareness • High expectations • Imperialist notions • How can solutions fit everyone • Where to start? • Quantitative tradition

16. Way forward • Where do we start? • Focus on key patient safety concerns • Manageable chunks • Contact with the real details of work is essential • End user engagement for sustainable interventions • Evaluation of interventions and their impacts

17. Moving forward… • HF can give insight into real work in practice • But who should look? • Difficulty of “outsider” seeing details • But “insiders” greater anxiety from peers • Also insiders see adaptations (‘workarounds’) as normal • Mutual dependency is crucial • Clinicians need scope, direction, research base • HF need focus, clarify issues, access

18. (4) NEW APPROACH • ‘Resilience’ moves the focus away from: • “What went wrong?” to “Why does it go right?!” • It shifts emphasis from simplistic reactions to error making toward valuing proactive focus on error recovery • Many errors caught before they reach the patient • e.g. approx. 1 in 20 samples mislabeled and may contain WBIT but less than 5 result in Sentinel Events annually in Victoria • We aim to investigate the multiple process errors are that contribute to WBITs but also the systems factors which pick up these errors and prevent patient harm (both in clinical and laboratory settings)

19. Researching resilience?

20. Final thoughts… • Common (mis)perceptions • Large scope of HF • Method not system experts… • Qualitative vs. Quantitative tradition • “Parachuting in” • Who’s the expert? Need for strong collaboration • Balancing practice improvement and evaluation Resilience is an HF concept that can benefit patient safety because it represents a change in emphasis from a traditional, reactive focus on errors to seeing humans as a defense against failure

21. Jeffcott S, Ibrahim J, Cameron P. Resilience in Healthcare and Clinical Handover. QSHC 2009; 18; 256-260.THE END: Thank You 