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Patient Safety And Human Factors Engineering Spring2006
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Patient Safety And Human Factors Engineering Spring2006

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The second Power Point in a 3 part seminar for nursing students during their medical surgical clinical rotation. …

The second Power Point in a 3 part seminar for nursing students during their medical surgical clinical rotation.
Adapted from Dr. John Gosbee MD, MS
VA National Center for Patient Safety
Tool Kit Available at www.patientsafety.gov in 2005.

Published in: Health & Medicine

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  • Thank you for your comments! This was the second of three one hour presentations with nursing students and physician assistant students. The VA National Center for Patient Safety toolkit was used to develop this module. Check out the references slide for great resources. Carolyn
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  • I am developing a safety course with the premise of the Safe Patient Handling program in an undergraduate program. Your presentation touches many of the points I attempt to make regarding Human and system factors for errors. I appreciate being allow to share this with my students. It is beneficial and well done.
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  • Start lecture by asking for information about tools and equipment used in the health care setting 50 years ago and currently??? Place this info on the board.
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    • 1. Patient Safety and Human Factors Engineering Anne Arundel Community College Arnold, MD Carolyn Jenkins MSN, RN Spring, 2006 Adapted from John Gosbee, MD, MS VA National Center for Patient Safety [email_address] www.patientsafety.gov
    • 2.
      • Describe human factors model.
      • Examine the use of Human Factors Engineering (HFE) principles as a problem-solving approach to identify and control patient safety hazards.
      • Perform a usability study with a simple product using human factors engineering principles.
      • Propose improvements to the product to increase usability and prevent potential adverse events and close calls.
      OBJECTIVES
    • 3. Kyle, L. (2005). First place winner. The faces of caring: Nurses at work. 105,6.
    • 4.
      • Designing systems devices, software, and tools to fit human capabilities and limitations
      • Using methods to gather unique information on:
        • Hidden needs of the end-user
        • Unexpected interactions between the system and the end-user
      • Taking advantage of knowledge bases about human-system interaction
      What is Human Factors Engineering?
    • 5. Broad Impact of Human Factors Engineering
      • Aviation (since 1940’s)
      • Nuclear Power
      • Space flight
      • Computer software and hardware (Xerox PARC 1970s)
      • Consumer products (Palm Pilot, Snakelight)
      • Railroad, motor vehicle, farm machinery, etc.
    • 6. Why should we care about good "Human Factors"? Human Factors applied early in the design process results in: • Increases in productivity, improved performance, and greater user satisfaction; • Reduced need for training, system maintenance, and user support; • Reduction in errors, incidents/accidents, and overall costs. http://www.hf.faa.gov/webtraining/index.htm FEDERAL AVIATION ADMINISTRATION Improved system design results in reduced costs and improved productivity/performance.                                                                                                                               
    • 7. http://www.baddesigns.com/ Bad Design Kills
    • 8. Human Factors Model Senses - Vision - Hearing
      • Psychomotor
      • Hand
      • - Feet
      • Input Devices
      • Buttons
      • - Foot pedal
      Output - CRT - Sound INTERFACE
    • 9. Radar Scope to Detect “enemy” ships
    • 10. Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
    • 11. Performance Graph (curve) 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
    • 12. How can we move the curve upwards? 100% 90% 80% 70% Time (hours) 1 2 3 4 Performance
    • 13. Demonstration: Stroop Effect Row 1 Row 2 Row 3
    • 14. Now, State the Color of the Text as Fast as You Can… Red Red Red Blue Blue Blue Yellow Yellow Yellow Green Green Green Row 1 Row 2 Row 3
    • 15. Again, State the Color of the Text as Fast as You Can… Red Red Red Blue Blue Blue Yellow Yellow Yellow Green Green Green Row 1 Row 2 Row 3
    • 16. Count the number of times the word “ RED ” appears in this example .
    • 17. “ Tell the nursing student to attach the oxygen mask and tubing to the green spigot” For further info, see http:// faculty.washington.edu/chudler/words.html#seffect J. Ridley Stroop (1935) Studies of Interference in Serial Verbal Reactions. Journal of Experimental Psychology , vol 18, 643-662 Patient Safety Correlation
    • 18. Knee-jerk vs. HFE-based Remedy Make “sure” to use the correct color Adaptor!? Better
    • 19.  
    • 20. HFE Example Patient Controlled Analgesia (PCA) Pump Redesign Existing Design New Design Lin, L., R. Isla, K. Doniz, H. Harkness, K.J. Vicente, and D.J. Doyle, 1998. Applying Human Factors to the Design of Medical Equipment: Patient-controlled Analgesia. Journal of Clinical Monitoring and Computing 14: 253-263.
    • 21. PCA: Programming Sequence Redesign Existing Design New Design Decision Message-guided Action Action Legend
    • 22. User population
      • Tested with 2 user populations:
        • Novice users
          • Nursing students n=12
        • Expert users
          • Recovery Room Nurses n=12
    • 23. Usability Evaluation of a PCA Pump: Measurements
      • Programming Errors Measured
        • Quantity
        • Severity
        • Subtask classification
      • Performance Measured
        • Programming Time
        • Task completion time
        • Subtask completion time
      • Mental Workload Ratings  NASA-TLX
      • Subjective Preference  Questionnaire
    • 24. PCA Pump Errors - Results
      • New Interface
        • 55% reduction in number of errors
        • Zero errors in entering drug concentration
      • Old interface
        • 8 drug concentration errors were made
        • 3 of these were not detected and were left uncorrected
      • Mode Errors
        • Old interface errors involved selecting the wrong mode (11 errors, 9 of which were eventually corrected
        • With the new interface, only 3 such mode selection errors occurred, all of which were eventually corrected
    • 25. Other Results
      • Task Completion Time
        • 11/12 end-users faster with new interface
        • Average 18% faster
      • No difference in Subjective Workload
      • Over 90% preference for new interface
    • 26. Healthcare “Systems ” Range from the Simple to Complex
      • Syringe, catheter bag and its tubing
      • O 2 cylinder, ECG machine, IV pump
      • Code cart, anesthesia work station
      • Hospital computer system
      • MRI control room and suite
      • ICU, ED, OR
    • 27. "Don't worry--it always beeps when you do that!"
    • 28. Multi-Channel Infusion Pump
    • 29.  
    • 30. Human Factors Engineering is about the whole system
      • What’s the design of the training and education
      • Labeling and instructions attached to device
      • Policy and procedures?
      • Layout and structure of
        • The room
        • The overall environment
    • 31. Human Factors Engineering and Your World
      • Anesthesiology
        • Design of alarms, monitors, and safety systems
      • Emergency Medicine
        • Design of decision-making tools and monitoring
      • Surgery
        • Design of hand tools and visualization devices (laparoscopy)
    • 32. Take home points:
      • Be aware of and take extra precautions during vulnerable times-( tired, hungry, new equipment or procedures)
      • Ask manufacturer for usability studies.
      • Evaluate new products and equipment so the USER voice is heard.
      • Trust yourself first. If the machine is giving you data that does not support your patient assessment, try another machine or test the machine on yourself.
      • Avoid work arounds. If some part of the machine is not working, send it to bio med.
      • Volunteer to work on product and equipment selection committees so the USER voice is heard.
    • 33. HFE Exercise: Groups of 3-4
      • One person as Director
        • Remind equipment user to think aloud.
        • Prevent others in the group from assisting the equipment user.
        • Lead subsequent discussion.
      • One person as equipment user
        • What is it?
        • What is it used for?
        • How is it used?
        • Use the device in the way you think it should be used
      • 2 – 3 Observers
        • Document actions, what is said, swear words, facial expressions etc.
    • 34. Human Factors Engineering
      • Website of Human Factors Design Problems Case Studies . http:// www.baddesigns.com / Examples of things that are hard to use because they do not follow human factors principles.
      • Human Factors and Ergonomics Society . The main professional organization in the United States. www.hfes.org
      • Food & Drug Administration Human Factors Section . Several documents about medical devices, errors, and the design process (e.g., “Do it By Design”) www.fda.gov/cdrh/humanfactors.html
      • FAA On-line Tutorial on Introduction to HFE. Good and free interactive site to see depth and breadth in pretty good format. See www.hf.faa.gov/Webtraining/Intro/Intro1.htm
      • Stroop Color Demonstration and other Cognitive Psychology Demos. Eric Chudler. University of Washington. faculty.washington.edu/chudler/words.html
      • Kitaoka, A. and H. Ashida: Phenomenal Characteristics of the Peripheral Drift Illusion. Vision Vol. 15, No.4, 261-262. 2003 http:// www.psy.ritsumei.ac.jp/~akitaoka/PDrift.pdf
    • 35.
      • Agency for Healthcare Research and Quality http://psnet.ahrq.gov
      • Center for American Nurses. Culture of Safety. On line Continuing Education offering http://www.centerforamericannurses.org/can/news/safetyce.htm
      • Institute For Safe Medication Practices 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006 http://www.ismp.org/
      • Joint commission International Center for patient safety Peter Angood MD Chief Patient Safety Officer
      • Maryland Patient Safety Center 6820 Deerpath Rd. Elkridge, MD 21075 –Mary Hofbauer Brown [email_address]
      • National Center for Patient Safety. http://www.patientsafety.gov Linda Williams RN linda.williams7@med.va.gov
      • National Coordinating Council for Medication Error Reporting and Prevention http://www.nccmerp.org
      • Open Directory http://dmoz.org/Health/Public_Health_and_Safety/Patient_Safety/
      • National Patient Safety Foundation: www.npsf.org
      • National Quality Forum: www.qualityforum.org
      • American Nurses Association Nursing World Patient Safety and Advocacy Website http://www.nursingworld.org/patientsafety/
      Web sites for Patient Safety
    • 36. References:
      • Kohn, L., Corrigan, J. & Donaldson, M. (Eds.) (2000). To err is human. Building a safer Health care system. Washington, DC: National Academy Press.
      • Lin, L., R. Isla, K. Doniz, H. Harkness, K.J. Vicente, and D.J. Doyle, (1998). Applying Human Factors to the Design of Medical Equipment: Patient-controlled Analgesia. Journal of Clinical Monitoring and Computing 14: 253-263.
      • Page, A. (Ed.).(2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: National Academy Press.
      • Veterans Administration National Center for Patient Safety. Patient Safety Curriculum Toolkit. Available at http://www.patientsafety.gov/PSC/PSCurric.html
      • Vicente, K. (Summer 2002). Professional ethics as a systems problem: A case study for teaching. Cognitia. 6,1. Retrieved September 2005 from http://cedm.hfes.org/Cognitia_6.pdf