In attempting to prevent active errors, one must consider the crucial difference between slips and mistakes as the solutions to these two errors are very different. Slips represent failures that occur when we perform activities we do reflexively and cause a lapse in concentration. These slips, or lapses, often occur in the face of competing sensory or emotional distractions, fatigue, or stress. Mistakes, by contrast, are due to incorrect choices, and more often represent a lack of experience, insufficient training, or negligence.
Mitigating the risk of slips requires attention to the designs of protocols, devices, and work environments, with strategies such as these:
Addressing latent failures often requires an in-depth analysis of an organization. Such an analysis should lead to a concerted effort to revise how systems of care work, how protocols are designed, and how individuals interact with the system. Specific solutions vary widely depending on the type of latent error, the severity of the error, and the availability of resources to address the issue. Stronger actions, such as standardizing technology, human factors-based engineering fixes, changing culture, system integration, and team coordination strategies require more time; however, evidence suggests this approach is more sustainable and effective and reduces cost over time.
Patient safety designs can fall into two categories:
Systems thinking is integral to human factors engineering. In human factors engineering, each layer of a system and its interconnected components are considered in designing to support human strengths and compensate for limitations. Human factors engineering is a discipline concerned with the understanding of interactions among humans and other elements of a system. It applies theory, principles, data, and methods to designs in order to optimize human well-being and overall system performance.
Human factors engineers are focused on enhancing the safety and usability of a medical device to improve the care delivery process or organizational structure (e.g., the supply chain management, hospital throughput). They seek to understand the numerous factors that affect system performance, including tasks, technologies, and physical environment, and then redesign the systems to improve patient safety and team performance. Frontline staff are the main players in working with the engineers in the redesign and testing the system.
The table below lists strategies used to redesign processes for high reliability and improved safety (The Joint Commission, 2015).
|Human Factors Engineering Strategies|
Human factors (HF) experts make it easier for the widest range of healthcare professionals to perform at their best while caring for patients. The goal of good human factor design is to accommodate all users in the system. This means that the design process should anticipate the needs of a novice accomplished well-rested, calm clinician as well as those of a fatigued, inexperienced one. The human factor experts use evidence-based guidelines and principles to design ways to make it easier to do things such as order medications, hand off information, chart medications and orders electronically, or move patients.
Human factor approaches have been used for decades in complex, high-risk fields such as aviation and nuclear power. Its use was limited in healthcare until the Institute of Medicine report in 1999, “To Err is Human: Building a Safer Healthcare System.” Despite the raised awareness, these approaches are not widely adopted, and further work is needed to integrate human factor methods and tools into efforts to improve healthcare across the continuum.
See the table below for examples of human factors and systems engineering (HF/SE) approaches to improving patient safety (Carayon, Wooldridge, Hose, Salwei, Benneyan, 2018).
|Safety issue||HF/SE approach||Example|
|Patient safety events and near misses||HF classification frameworks and methods for analyzing system factors that contribute to the events and near misses||Human Factors Analysis and Classification System (HFACS) (note 21)|
|Medication safety||Human-centered design of medication processes, such as prescription and administration||HF design principles and HF methods for safer design of order-prescribing interfaces (note 16) and code cart medication drawer (note 25)|
|Healthcare-associated infection||Analysis of system factors that contribute to the infections||Identification of work-system barriers and facilitators to adherence to contact isolation for patients with suspected or confirmed Clostridium difficile infection (note 17)|
|Patient falls||HF design of work systems for reducing inpatient falls||Human-centered design of fall prevention toolkit (note 19)|
|Patient identification||Human-centered design of identification armband||HF design of armband for improving patient identification by reducing number of visual scans required (note 20)|
|Patient safety in primary care||Work system analysis for patient safety||Efforts to counteract the "information chaos" experienced by primary care physicians that can lead to patient safety events (note 30)|
|Patient safety in home care||HF/SE analysis of medical devices and information technologies used in the home||Analysis of usability and system integration of hemodialysis technology (note 32) and infusion pump (note 33); HF design of consumer health information technologies for home use (note 31)|
|Patient safety in care transitions||Process analysis of transitions between hospital and home (note 37)||Description of transition process and safety vulnerabilities over multiple phases of care, especially for older adults (note 36)|
Patient safety draws on a range of disciplines, such as human error, human physiology, psychology, and sociology. Systems analysis and improvement come from engineering and management. Safety uses controlled experiments, scientific methods, and human factors engineering that is built on human performance, anatomy, physics, mathematics, and physiology. It draws from any discipline that is appropriate to what we are studying or analyzing in patient safety.
Authored by Cindy Ebner, MSN, RN, CPHRM, FASHRM
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