Analyzing Human Factors that Contribute to Patient Safety

Facilitator's Guide and Outline

Rationale

  • National medical errors data.
  • Local medical errors data.
  • HF engineering is key to identifying causes of errors and reducing recurrence.
  • HF problems & solutions can be addressed by individuals as well as the whole institution.

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Grabber

  • What’s wrong with this picture?
  • Can you think of anything similar in your work setting?

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Introduction

  • Human errors are inevitable, in medicine too.
  • Understanding why we err, and how to reduce repetition is important.
  • Human factors engineering is a key tool in error reduction for health care providers.
  • Those who encounter the problems should be involved in resolving them.

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Definitions

  • Human factors

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Key Message #1

Human factors as it relates to design

  • Interactions with machines and objects
  • Negative impact of environmental conditions
  • Workarounds
  • Unintended consequences

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Key Message #2

Your institution’s disclosure policy and procedure

  • Who’s responsible
  • Who needs to be notified
  • What (if anything) is written
  • What’s practiced
  • What’s causing any discrepancy between policy and practice

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Key Message #3

Human factors as it relates to interactions with other people

  • Communication
  • Mental models
  • Teamwork

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Examples of human factors in everyday life

Key Message #4

Human factors in patient safety

  • Similarities and differences
  • Re: machines and devices
  • Re: work environment
  • Re: unintended consequences
  • Re: working with other people

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Examples of human factors in patient safety

Key Message #5

Human factors findings from other industries

  • Which industries have applied this science
  • Common fundamentals
  • Scientific method
  • Six step process for analysis

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Key Message #6

Applying human factors science to health care

  • Observation
  • Analysis
  • Solutions

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Key Message #7

Best practices in health care human factors

  • Reducing reliance on memory
  • Improving information access
  • Decreasing error opportunities
  • Simplification

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Summary

HF lead to medical errors that can be reduced through application of a scientific methodology.

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