Human factors nhsiq 2014

© NHS Improving Quality 2014
Human Factors: Human Error?
To Err is Human
– Planning for the human element in healthcare
Patient Safety Team

The amazing colour changing
card trick

If someone makes a
mistake is it due to
………………….
• Human Error?
• Human Unreliability?
• Human Performance Problem?

Human Error
“We cannot change the human condition but we
can change the conditions under which
humans work.”(Reason, 2000)
“Blaming individuals is emotionally more
satisfying than targeting institutions.” (Reason, 2000)
“Human error is the failure of desired actions to
achieve their desired ends.” (Reason, 1990)

Planning for the human
element in healthcare
• Why were medicines given to the wrong patient?
• Why was the needle recapped before disposal?
• Why lift manually when a ceiling lift was
available?
• Why weren’t gloves and a mask worn?
• Why was the patient agitation/pain not noticed?

What is human error?
“Human error is a failure of planned actions to
achieve their desired ends” (Reason, 1990)
PLAN
PLANNING
MISTAKES
EXECUTION
ERRORS
ACTIONS OUTCOME

What is human error?
It is an imbalance between
• what the situation requires
• what the person intends
• what he/she does

Human error happens when…
• Plan to the right thing but with the wrong
outcome
• Do the wrong thing for the situation
• Fail to do anything when action is required

Why do errors happen?
• Simply put errors happen when multiple
factors come together to allow them to
happen
• Human error = System error

Human Factors Issues
• Errors are the result of a system as a whole
• Context is everything
• No longer about
– Naming
– Blaming
– Shaming
– Retraining
• Isolate errors from context and human factors has little or
no remedial value

Why is this important?
Example: Medication Error
Primary Consequence: Patient’s Health
Other Consequences:
• Increased workload for patient care
• Stress, anxiety, guilt for health care professionals
• Stress for supervisors and managers
• Financial consequence for the organisation

The system model (Reason 2006)
• Fallibility is part of the human condition
• Adverse events are the product of latent
pathogens within the system
• Sharp enders are more likely to be the
inheritors than the instigators
• Remedial effort is directed at improving
differences and removing error traps
• Need safety culture to motivate personal
responsibility to prevent errors

Reason’s Accident Causation
Model
• Latent Conditions
• Error producing conditions
• Active failure
• Defences

The Swiss cheese model of how defences, barriers, and
safeguards may be penetrated by an accident trajectory.
Reason J BMJ 2000;320:768-770
©2000 by British Medical Journal Publishing Group
Mitigation
Recognition
Prevention
Policy
Leadership
Rapid
Response

Active Failure
• Active failure
– Occur at the level of the front line operator
– Slips, lapses and mistakes
– Violations (deliberately ignoring rules)

Error Producing
Conditions
• Error producing conditions
– Environmental
– Team
– Individual
– Task factors which effect performance

Personal & environmental factors
• Personal Factors
• Fatigue
• Lack of sleep
• Illness
• Irregular work patterns
• Drugs or alcohol
• Boredom
• Frustration
• Fear
• Shift work
• Reliance on memory
• Reliance on vigilance
• Environmental Factors
• Distractions
– Noise
– Heat
– Clutter
– Motion
– Lighting
• Too many handovers
– Unnatural workflow
• Poorly designed procedures or
devices
• Inadequate training and skills

A smoke filled room

Latent Conditions
• Tend to be removed from the direct control of
the operator
• Poor design
• Incorrect installation
• Faulty maintenance
• Bad management decisions
• Poorly structured organisations

Defences

Human Factors Gear Box

Skills Rules Knowledge
Framework (Rasmussen, 1983)
Automatic
Conscious
Rule Based
Knowledge Based
Skill Based
Unskilled or occasional user
Novel environment
Pre-packaged behaviour e.g. if the symptom is X then the
problem is Y, OR if the problem is Y do Z
Automated and requires little conscious attention

Conscious
Control Mode
Automatic
Situation
Routine
Novel Problem
Skill based
Behaviour
Rule based
Behaviour
Knowledge
based
Behaviour

Slips and Mistakes
• Slips
– Intention is correct but a failure occruing when
carrying out the activity required
• Mistake
– Incorrect intention which leads to an incorrect
action sequence. These usually occur due to lack
of knowledge.

Human Error Taxonomy
Human
Failure
Violations
EXCEPTIONAL:
Boundaries are changed in
Order to full fill rush order
Routine:
Operator does not follow
Because out of date
Errors
MISTAKESSLIPS
KNOWLEDGE BASED
A LACK OF EXPERTISE
RULE BASED
A failure of expertise e.g.
Wrong diagnosis
SKILL BASED
Misapplied competence e.g.
Operator fails to close one valve
Due to confusion with another

Managing Human Error in
Healthcare
1. Prevent Error
2. Recognise Error
3. Mitigate Error

Use Human Factors Knowledge to
design systems
• Standardise the work environment
• Select equipment with safety features
• Provide backup for critical personnel and
equipment
• Provide clear supervision and direction

Example
The pharmacy porter whose job it is to deliver
medicines to the wards injures their shoulder
and is unable to work

Simple Analysis
Pushing the trolley caused the injury

Human Factors Analysis
• The porter had had a sore shoulder for many
weeks but had failed to report his symptoms
because they could still work (error in early
reporting and porter training)
• The trolley was old and didn’t run in a straight
line because the wheels were wonky. (error in
policy and maintenance)
• The trolley was too tall to see over when full;
therefore full trolleys were pulled instead of
pushed. (error in purchasing and job design)

Exercise
• Discuss the last error that you were involved
in / analysed and consider this from a human
factors perspective.
• How does the theory apply to this?
• Knowledge
• Skill
• Behavioural errors

Human Error
Type
Typical Forms Common Prevention
Strategies
Slip / Lapse • Double capture
• Omission
• Interference
• Perpetual
Confusion
• Minimising Interruptions
• Forcing Functions
• Colour coding, highlighting
differences
• Checklists, memory aids
Rule Based
Mistake
• Strong but wrong
• Exception to rule
• Cognitive Overload
• Minimise / highlight
exceptions
• Provide feedback
• Manage workload
Knowledge based
mistake
• Confirmation bias
• Out of sight, out of
mind
• Decision support
• Team work
Summary

Exercise
• Look at your process and consider how you
will include Human Factors in your design.
• Think about how you will observe your
process through fresh eyes.
Insert date/time

How it fits
• Now is the time to use your safety
improvement knowledge:
• Human Factors
• Model for Improvement
• PDSA and small tests of change
• Metrics and measurement for Improvement
• Engagement
• Spread and adoption
• Sustainability

Human factors nhsiq 2014

More Related Content

What's hot

Viewers also liked

Similar to Human factors nhsiq 2014

More from NHS Improving Quality

Recently uploaded

Human factors nhsiq 2014