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NPSF Professional Learning Series presents:Applying Human Factors Engineeringand Systems Safety Approachesin Health CareRollin J. (Terry) Fairbanks, MD, MS, FACEPAttending Emergency Physician, MedStar Washington Hospital CenterAssociate Professor of Emergency Medicine, Georgetown UniversityDirector, National Center for Human Factors Engineering in HealthcareMedStar Institute for Innovationwww.MedicalHumanFactors.netApril 25, 2012

Participant NotificationContinuing Education*:This educational activity offers 1.0 contact hours.PharmacyInquisit ® is accredited by the Accreditation Council for Pharmacy Education as a provider ofcontinuing pharmacy education. This program will provide 1.0 ACPE Contact Hours underprogram number 232-999-12-086-L04-P.NursingInquisit is accredited as a provider of continuing nursing education by the American NursesCredentialing Center’s COA.Inquisit is Iowa Board of Nursing provider 333 and 1.2 contact hours will be awarded for this program.*Continuing education credits are only available for live webcasts. A post-event survey must becompleted within 7 days of participation to receive continuing education credits.2NPSF Professional Learning SeriesApril 25, 2012

DisclosureFaculty DisclosureRollin J. (Terry) Fairbanks, MD, MS, FACEP has disclosed no relevant, real orapparent personal or professional financial relationships.Acknowledgement of Commercial SupportThere was no commercial support received for this CME activity.Questions?Contact Us at info@npsf.org or 617-391-99003NPSF Professional Learning SeriesApril 25, 2012

Learning Objectives• Describe the systems approach to safety engineering• Describe how human factors engineering can impactsafety• Describe implications of system design, medical devicedesign, and health IT design in this context• Describe approaches to serious safety event reviewsthat will produce sustainable results• Describe how a just culture approach is important to theintegration of a system safety engineering approach.4NPSF Professional Learning SeriesApril 25, 2012

NPSF Professional Learning Series presents:Human Factors Engineeringand Systems Safety Approachesin Health CareRollin J. (Terry) Fairbanks, MD, MS, FACEPAttending Emergency Physician, MedStar Washington Hospital CenterAssociate Professor of Emergency Medicine, Georgetown UniversityDirector, National Center for Human Factors Engineering in HealthcareMedStar Institute for Innovationwww.MedicalHumanFactors.netApril 25, 2012

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The Problem• IOM Report in 2000:– Est. 44,000-98,000 deaths/year• Government mandate:50% less error in 5 years• 12 Years later….ESSENTAILLY NO CHANGE!!-----WHY?-----Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. May 18 2005;293(19)Wachter RM. The end of the beginning: Patient Safety Five Years After 'To Err Is Human'. Health Aff. 2004(11)Wachter RM. Patient Safety At Ten: Unmistakable Progress, Troubling Gaps. Health Aff. 2010 (29:1)Landrigan, Parry, et al. Temporal Trends in Rates of Patient Harm Resulting from Medical Care. NEJM 363(22): 2010Shekelle, Pronovost, et al. Advancing the science of patient safety. Ann Int Med 154(10): 2011Longo, Hewett, Ge, Schubert. The long road to patient safety: a status report on patient safety systems. JAMA, 294(22): 2005.7NPSF Professional Learning SeriesApril 25, 2012

Systems ApproachIs the goal to : “Eliminate Error?”NO• Human Error cannot be eliminated▫ Futile goal; misdirects resources/focus▫ Causes culture of blame and secrecy• “name, blame, shame, and train” mentality• It is about reducing HARM• retraining, policy, memos, M&M, etc do notcreate sustained improvement in safety8NPSF Professional Learning SeriesApril 25, 2012

Chart Credit: Modified from L. Leape9NPSF Professional Learning SeriesApril 25, 2012

Systems Approach• Pilots and ATC – make 2 errors per hour• Yet aviation: highly reliable, resilient, SAFE• Healthcare: 1 fatality per 10,000 admissionsOdds of being on an airline flight whichresults in at least one fatalityTop 25 airlines with the best accident rates1 in 5.4 millionOdds of being killed on a single airlineflightTop 25 airlines with the best accident rates1 in 9.2 millionfatal accidents fatalitiesDriving 1.32 1.47Airlines .05 1.57per 100 million milesSources: OAG Aviation & PlaneCrashInfo.com accident database, 1985 – 2009 ; Hayward &Hofer, JAMA 200110NPSF Professional Learning SeriesApril 25, 2012

Accident Causation Pyramid“Tip of the iceburg”• 1 serious or major injury• 10 minor injuries• 30 property damage injuries• 600 incidents with no visibledamage or injuryBird, 19691,753,498 accidents from 297 companies, 21 different industriesSlide acknowledgment: Robert Panzer, MD11NPSF Professional Learning SeriesApril 25, 2012

Human Factors Engineering (HFE)• Human Factors Engineering:▫ Optimize relationship between technology andthe human user: “Designing for human use”▫ Prominent in aviation, nuclear, military• Human Computer Interaction (Usability)▫ Ease of use and minimized use error• Cognitive Systems Engineering▫ Useful to support the work of the end user12NPSF Professional Learning SeriesApril 25, 2012

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Defibrillator Case• VF cardiac arrest• Nurse with patient• charges unit…• clears patient…• then presses “on”button• Machine powers down• 2 minute delay in shock15NPSF Professional Learning SeriesApril 25, 2012

Defibrillator Case• MEPARS.com: 3 EMS Reports• Simulation study (Denmark)▫ 72 physicians using common device▫ 5 of 192 defib attempts: device powered down• Mean delay: 24 seconds▫ Device can be turned off even if charged &readyHoyer, Christensen, et al. (2008). "Adverse designof defibrillators: turning off the machine whentrying to shock." Annals of Emergency Medicine52(5): 512-514.16NPSF Professional Learning SeriesApril 25, 2012

Huh?17NPSF Professional Learning SeriesApril 25, 2012

Defibrillator Case #2• 32 year old healthy man w/wife, young kids• Presents to ED with rapid heartbeat▫ Non-life threatening condition (SVT)• Synchronized shock @50j refractory• Try again @ 100j VF Arrest• 45m resuscitation attempt patient dies• Investigation reveals that MD failed to putdevice in SYNC mode for second shock18NPSF Professional Learning SeriesApril 25, 2012

Defibrillator Usability Study• Fourteen expert participants• Four tasks: 2 routine, 2 emergent• Two defibrillator models• SimMan TM patient simulator• 50% of participants inadvertentlydelivered an unsynchronizedcountershock for SVT▫ 71% of participants never aware‣Fairbanks RJ, Caplan SH, et al. Usability Study of Two Common Defibrillators Reveals Hazards.Annals of Emergency Medicine Oct 2007; 50(4): 424-432.[See also associated editorial: Karsh and Scanlon, Oct 2007; 50(4): 433-435]19NPSF Professional Learning SeriesApril 25, 2012

Response“Physician should have taken time to askED staff for an operator’s manual for thedefibrillator and read it after he arrived inthe ED to perform a cardioversion”“the preventative or corrective action isprovided in the device labeling”Fairbanks RJ and Wears RL. Hazards With Medical Devices: the Roleof Design.Annals of Emergency Medicine Nov 2008; 52(5): 519-521.20NPSF Professional Learning SeriesApril 25, 2012

Labelsdon’t workPhoto Credit: Neighborhood Watch (Fox, 2012 movie)21NPSF Professional Learning SeriesApril 25, 2012

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Cognitive systems engineering:Example: Transition to Health IT26NPSF Professional Learning SeriesApril 25, 2012

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today5 months ago5 months ago30NPSF Professional Learning SeriesApril 25, 2012

Who knows?31NPSF Professional Learning SeriesApril 25, 2012

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Prescription Writing Task1133NPSF Professional Learning SeriesApril 25, 2012

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Anatomically orientedIs this the best way?National Center for Human Factors Engineering in Healthcarewww.MedicalHumanFactors.

Example…Multiple inpatientPEs occur over 2yearsAudit: 50%Compliance withHospital VTEguideline…WHY are those doctorsso non-compliant?36NPSF Professional Learning SeriesApril 25, 2012

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Result of CPOE Pathway• Readily accepted by physicians• Increase in appropriate prophylaxis rates50% 66% 93%Fairbanks RJ, Caplan S, Panzer RJ. Integrating Usability Into Development Of A ClinicalDecision Support System. Proceedings of HCI-International 2005, Mira DigitalPublishing (ISBN 0-8058-5807-5). July 2005; Las Vegas, Nevada.40NPSF Professional Learning SeriesApril 25, 2012

23 minutes…41NPSF Professional Learning SeriesApril 25, 2012

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Fatal Arrhythmia:Patient is dyingArtifact:Patient is moving43NPSF Professional Learning SeriesApril 25, 2012

Alarms• Placement ofmonitorsNurses sitalong here44NPSF Professional Learning SeriesApril 25, 2012

Alarm Fatigue• There is no clinically significant interactionbetween ibuprofen and famotidine45NPSF Professional Learning SeriesApril 25, 2012

Too soft, you say?46NPSF Professional Learning SeriesApril 25, 2012

Just Culture:The Three BehaviorsNormalErrorAt-RiskBehaviorRecklessBehaviorInadvertent action: slip, lapse,mistakeA choice: risk not recognizedor believed justifiedConscious disregard ofunreasonable riskManage through changes in:Manage through:Manage through:• Processes• Procedures• Recurrent training• Design• Environment• Removing incentives for At-Risk Behaviors• Creating incentives forhealthy behaviors• Increasing situationalawareness• Re-examining environment• Remedial action• Punitive actionSupport Coach SanctionAdapted from: David Marx, Just Culture. Outcome Engineering 2008: www.JustCulture.orgSee also, Just Culture: Balancing Safety and Accountability, Sidney Dekker (2008)47NPSF Professional Learning SeriesApril 25, 2012

Reducing Risk:Where should we focus?• Focus on Hazards▫ Near misses▫ Dangerous conditions, situations, etc▫ Recognize and report hazards▫ Develop the culture by recognizing system contributions• Then you’ll learn more about hazards in your system▫ RCAs• Recognize the system contributions• Examine with the lens of human factors▫ Ask staff about “accidents waiting to happen”48NPSF Professional Learning SeriesApril 25, 2012

Reducing Risk:Where should we focus?• Focus on contributing factors that can bechanged▫ System factor focus in RCAs & incident reviews▫ System and device/IT design to support worker▫ Study near misses▫ Non-punitive QA systems/Just Culture▫ Culture change-facilitated by leadership▫ Red Rules? Leadership’s responsibility49NPSF Professional Learning SeriesApril 25, 2012

What DOES NOT reduce risk• Changes after an adverse event/RCA:▫ “Failure to follow policy” (or procedure) asprimary root cause▫ “Develop policy” or “train staff” or “counsel” asprimary action▫ “Human Error” as a cause without contributingfactors▫ Any flavor of the “name, blame, and train”approach50NPSF Professional Learning SeriesApril 25, 2012

Putting it to work• Facilitate culture change• Open lines of communication (reporting)• Employ system safety analysis techniques• Enact protective system changes (slices)• No “name, blame, shame, & train”• “I could have told you that was going tohappen…”51NPSF Professional Learning SeriesApril 25, 2012

Final Thoughts…• 12 years later….Why No Change?– Focus is STILL on the individual– Focus is on local level– Team dynamics– Communication– Hierarchical Culture– Culture of Blame52NPSF Professional Learning SeriesApril 25, 2012

Final Thoughts…• Fallibility is part of the human condition• We cannot change the human condition• We can change the conditions under whichpeople work--Jim Reason53NPSF Professional Learning SeriesApril 25, 2012

Easy Reads** & Reference**Set Phasers on Stun, Steve Casey (1998)**The Design of Everyday Things, D. Norman (1988)**The Field Guide to Understanding Human Error (2006) SidneyDekker** Just Culture: Balancing Safety and Accountability, SidneyDekker (2008)Handbook of Human Factors and Ergonomics in Health Care andPatient Safety, 2 nd ED; P. Carayon (2012)Patient Safety in Emergency Medicine. Croskerry, Cosby,Schenkel, and Wears (2009)Human Error, James Reason (1990)Normal Accidents, Charles Perrow (1984)54NPSF Professional Learning SeriesApril 25, 2012

Rollin J. (Terry) Fairbanks, MD, MS, FACEPDirectorNational Center for Human Factors Engineering in HealthcareMedStar Institute for InnovationAssociate Professor of Emergency MedicineGeorgetown University School of MedicineAdjunct Associate Professor of Industrial Systems EngineeringUniversity at Buffalo School of EngineeringEmergency Medicine Attending PhysicianMedStar Washington Hospital Centerwww.MedicalHumanFactors.netTerry.Fairbanks@MedicalHFE.org55NPSF Professional Learning SeriesApril 25, 2012

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