Human Factors

Support Materials

Slide Presentation

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References

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  1. To Err is Human
  2. Crossing the Quality Chasm
  3. Sheridan TB. Humans and Automation: System Design and Research Issues. John Wiley & Sons: Hoboken, NJ. 2002
  4. Chapanis A. Human Factors in Engineering Design. 1996. New York, NY: Wiley
  5. Leape LL. Error in medicine. Journal of the American Medical Association. 1994; 272: 1851-7
  6. Senge P. The Fifth Discipline. New York, NY: Currency Doubleday. 1990
  7. Leval M, et al. Human Factors and Cardiac Surgery: A Multicentre Study, Research Grant from the British Heart Foundation

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Facilitator's Guide and Outline

A full outline of the key messages for this module, including links to slides, references, and facilitation tips.

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Video

First, Do No Harm

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Facilitation Tips

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  1. Design

    Bring a physical example of a poorly designed product to your meeting.

    • Ask someone in the audience to use it. (Pass it around for people to try.)
    • Ask the volunteer and the audience what is wrong with this product and why. (Elicit the answer that it's difficult to use because of a design flaw. It's not obvious what to press to make it go or it's difficult to press the button or awkward, etc.)
    • Use the audience response to lead into the discussion of objects and systems in health care that make it easy to make mistakes.
    • Expand to the human factors principles of what is difficult for humans, how devices and systems SHOULD be able to support human functioning and reduce errors.

    Lead back to what can happen when humans don't remain tuned in to systems or device flaws, and human assumption that things will work they way they were intended rather than how they were (imperfectly) designed.

  2. Examples

    As you describe the types of errors, ask the group to come up with examples in their own department or hospital or office setting. The examples can positive (i.e., a supportive system, piece of equipment, or design) or negative. Bad ones are plentiful and more fun. If time allows, ask them how to make the object of their example better.

  3. Goals for Improvement

    Hand out a sheet listing Design defects; Knowledge deficits; Environmental hazards, Physical incapacities to each person. Ask the group to go on a scavenger hunt in the nearby area (or email back their list within one week) with as many examples as they see in their own work environment under each category. Assure them that no one will be publicly singled out for identifying problems. Provide a prize for the person with the highest number. Share the list (not the winning name) as “Goals for Improvement.”

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Exercise

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