usability and human factors human factors and healthcare lecture b this material (comp15_unit4b) was...

Usability and Human Factors

Human Factors and Healthcare

Lecture bThis material (Comp15_Unit4b) was developed by Columbia University, funded by the Department of Health and Human

Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.

Human Factors and HealthcareLearning Objectives

2

• Describe the different dimensions of the concept of human error (Lecture b)

• Describe a systems-centered approach to error and patient safety (Lecture b)

Health IT Workforce Curriculum Version 3.0/Spring 2012

Usability and Human Factors Human Factors and Healthcare

Lecture b

Patient Safety

http://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_license

3Health IT Workforce Curriculum Version 3.0/Spring 2012


Lecture b

• Healthcare discipline emphasizes reporting, analysis, and prevention of medical error.

• Landmark Report: Institute of Medicine (1999)• Magnitude of the

problem not known

http://www.flickr.com/photos/andyde/4762081047/sizes/l/

Harvard Medical Practice Study



Lecture b

Why do Errors Happen?



Lecture b

• Error is the failure of a planned sequence of mental or physical activities to achieve its intended outcome when these failures cannot be attributed to chance

• Inclination to blame somebody– Who is responsible? Often the person closest to the

failure becomes the one who gets blamed• Can we isolate a single cause?• “When human error is viewed as a cause rather than

a consequence, it serves as a cloak for our ignorance” (Henriksen et al, 2008).

• Systems-centered approach:– Latent Conditions and Active Failures (Reason, 1997)

Active Failure

• Occur at the level of the frontline operator– Effects are felt immediately

• In health care, active errors are committed by providers (e.g., nurses, physicians, pharmacists) who are actively responding to patient needs at the “sharp end”



Lecture b

Latent Conditions (Reason, 1990)



Lecture b

Hindsight Bias



Lecture b

Space Shuttle Challenger Disaster

http://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.html



Lecture b

• Space shuttle exploded on takeoff in 1986 killing 8 crew members

• Cause: O-ring seal in rocket booster failed at liftoff

• Multiple faults including unanticipated cold weather, brittle O-ring seals, communication problems between NASA and contractors, etc.

• Latent errors went unrecognized


Deepwater Horizon Explosion

http://www.flickr.com/photos/skytruth/4733160839/sizes/l/



Lecture b


Reason “Swiss Cheese” Model of Error

Reason, J (2000).



Lecture b

AdverseEvent

OrganizationInfluences Unsafe

Supervision Preconditions for Unsafe Acts

ActiveFailures

LatentFailures

LatentFailures

LatentFailures

• Slips:– Incorrect execution of

a correct action sequence

• Errors when routine behavior is misdirected or omitted

• Mistakes:– Correct execution of

an incorrect action sequence

• Errors in judgment, perception, inference or interpretation

Human Errors



Lecture b

• Knowledge-Based– Faulty conceptual

knowledge– Incomplete knowledge– Biases and faulty

heuristics– Incorrect selection of

knowledge– Information overload

• Rule-Based– Misapplication of good

rules– Encoding deficiencies

in rules– Action deficiencies in

rules– Dissociation between

knowledge and rules

Mistakes



Lecture b

Example: Error One

• Description of the environment/case study information:– Mr. B is a 45 year old male being treated for

dehydration secondary to nausea, vomiting and diarrhea

– Mr. B has been in the Intensive care Unit (ICU) for 4 days receiving intravenous fluids via an IV catheter in his right forearm

– As Mr. B stabilizes, the physician orders to start P.O. fluids (fluids by mouth) and discontinue the IV fluids

• Note, the order is to discontinue the IV fluids, not the IV• Typically, the RN will stop the IV fluid and convert the IV to a

saline lock that may be used for intermittent infusions as necessary



Lecture b

Example: Error One (cont.)



Lecture b

Example: Error Two

• Mr. Jones is assigned to a team of nurses for the dayshift• One nurse responsible for giving medication to patients on the team• Other nurse responsible for all assessments & treatments• Mr. Jones complains of pain to the treatment nurse• Rather than delay the pain medication waiting for the medication nurse,

treatment nurse obtains narcotic and administers it to Mr. Jones• Treatment nurse forgets to document on medication record that she gave

Mr. Jones some Demerol for pain• When making rounds, medication nurse asks Mr. Jones if he is in pain• Mr. Jones again replies yes• Medication nurse reviews medication record -- no documentation of pain

medication given• She medicates Mr. Jones with Demerol (again)• Within 1 hour, Mr. Jones is lethargic & has respiratory depression• He has to be transferred to ICU for closer monitoring due to Demerol

overdose



Lecture b

Example: Error Two (cont.)



Lecture b

Interdependence of The Health Care System

• “Healthcare is composed of a large set of interacting systems - paramedic, and emergency, ambulatory, inpatient care and home health care; testing and imaging laboratories; pharmacies that are connected in loosely coupled but intricate networks of individuals, teams procedures, regulations, communications, equipment and devices that function with diffused management in a variable and uncertain environment” (p 158)

» Kohn et al, (2000)To Err is Human



Lecture b

Systems Approach to Adverse Events in Health Care



Lecture b

External Environment

Knowledge Base

Demographics

New Technology

Gov’t Initiatives

Economic Pressures

Health Care Policies

Public Awareness

Political Climate

Management

Patient Load

Staffing

Organization/Safety Culture

Accessibility of Personnel

Leadership Involvement

Physical Environment

Lighting

Noise

Workplace Layout

Distractions

Human-System Interface

Medical Devices

Equipment Location

Controls and Displays

Paper/electronic Charts

Distractions

Org/Social Environment

Authority Gradients

Group Norms

Communication/Coordination

Local Procedures

Work Life Quality

Systems Approach to Adverse Events Continued



Lecture b

Nature of the Work

Treatment Complexity

Workflow

Individual vs. teamwork

Competing Tasks and interruptions

Physical/Cognitive Requirements

Individual Characteristics

Knowledge/Skills

Experience

Physical Capabilities

Alertness/fatigue

Motivation/Attitude

Cultural Competency

AcceptablePerformance

Sub-StandardPerformance

PredictableAdverse Event

1.2 Chart: (Henriksen, 2008)

Medical Errors

1.3 Chart: (Zhang et al, 2004)



Lecture b

Near Miss

Boundary

Normal Routine

Adverse Event ReportBoundary

Violation of consensual bounds of safe practice Error recovery: Detection and

correction of violation

Human Factors and HealthcareSummary – Lecture b

• Patient Safety and human error

• Reason model of error– Slips and mistakes– Knowledge vs rule-based mistakes

• Systems approach to medical error

• Next lecture: Workload, medical devices and mental models



Lecture b

Human Factors and HealthcareReferences – Lecture b

Reference

Carayon, P. (Ed.). (2007). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ: Lawrence Erlbaum Associates.

Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding Adverse Events: A Human Factors Framework. In H. R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 84-101). Rockville, MD: Agency for Healthcare Research and Quality

Horsky, J., Kaufman, D.R., Oppenheim, M.I. & Patel, V.L. (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. Journal of Biomedical Informatics, 36, 4-22.

Kaufman, D. R., Pevzner, J., Rodriguez, M., Cimino, J. J., Ebner, S., Fields, L., et al. (2009). Understanding workflow in telehealth video visits: Observations from the IDEATel project. Journal of Biomedical Informatics, 42(4), 581-592.

Kaufman, D.R. & Starren, J. B. (2006). A methodological framework for evaluating mobile health devices. In the Proceedings of the American Medical Informatics Annual Fall Symposium. Philadelphia: Hanley & Belfus. 978

Kaufman, D.R., Patel, V.L., Hilliman, C., Morin, P.C., Pevzner, J, Weinstock, Goland, R. Shea, S. & Starren, J. (2003). Usability in the real world: Assessing medical information technologies in patients ’ homes. Journal of Biomedical Informatics, 36, 45-60.

Reason, J.T. (1997) Managing the risks of organizational accidents. Ashgate Pub;ishing, Aldershot, UK.

Reason, J.T. (1990) Human Error. Cambridge University Press, Cambridge.

Kohn, L.T., Corrigan, J., and Donaldson, M. (2000). To Err is Human. Institute of Medicince, National Academy Press. Washington, Dc.



Lecture b

Human Factors and HealthcareReferences – Lecture b

Images

Slide 3: Retrieved on September 10th, 2010 from http://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_license

Slide 9: Retrieved on September 10th, 2010 from http://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.html

Slide 10: Retrieved on September 10th, 2010 from http://www.flickr.com/photos/skytruth/4733160839/sizes/l/

Slide 11: Reason J (2000). Human error: models and management. BMJ, 320:768-70

Charts, Tables and Figures

1.1 & 1.2 Chart: Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding Adverse Events: A Human Factors Framework. In H. R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 84-101). Rockville, MD: Agency for Healthcare Research and Quality

1.3 Chart: Zhang, J., Patel, V. L., Johnson, T. R., & Shortliffe, E. H. (2004). A cognitive taxonomy of medical errors. J Biomed Inform, 37(3), 193-204.



Lecture b

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usability and human factors human factors and healthcare lecture b this material (comp15_unit4b) was...

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