Presented to 1st
Year Postgraduate Medical Students at the Faculty of Medicine King Fahad
Medical City, Riyadh on February 25, 2013 by Professor Omar Hasan Kasule Sr.
Key
words: Human factors, ergonomics, systems, human performance.
LEARNING
OBJECTIVES
·
Overall: Understand
human factors and its relationship to patient safety.
·
Knowledge and
performance What a student needs to know(knowledge requirements): (a) explain
the meaning of the term“human factors”; (b) explain the relationship between
human factors and patient safety.
·
What a student
needs to do (performance requirement):• apply human
factors thinking to your work environment.
DEFINITION
·
Human factors
examines the relationship between human beings and the systems with which they
interact
·
It focuses on improving efficiency, creativity, productivity and job satisfaction, with the
goal of minimizing errors.
·
A failure to
apply human factors principles is a key aspect of most adverse events in health
care.all health-care workers need to have a basic understanding of human factors
principles.
THE
MEANING OF THE TERMS “HUMAN FACTORS” AND “ERGONOMICS”
·
The terms human
factors and ergonomics (as it is sometimes called) are used to describe interactions
between three interrelated aspects: individuals at work, the task at hand and the workplace itself.
·
We define human
factors as: the study of all the factors that make it easier to do the work
in the right way.
·
Another
definition of human factors is the study of the interrelationship between
humans, the tools and equipment they use in the workplace, and the environment
in which they work.
HUMAN
FACTORS IN HEALTH CARE 1
·
In health care,
human factors knowledge can help design processes that make it easier for
doctors and nurses to do the job right.
·
Human factors
applications are highly relevant to patient safety because embedded in the
discipline of human factors engineering are the basic sciences of safety.
·
Human factors
can show us how to make sure we use safe prescribing practices, communicate
well in teams and hand over information to other health-care professionals. These
tasks, once thought to be basic, have become quite complicated as a result of
the increasing complexity of health-care services and systems.
·
Much of health
care is dependent on the humans—the doctors and nurses—providing the care.
·
Human factors experts believe that mistakes can be reduced by focusing on the
health-care providers and studying how they interact with and are part of the environment.
HUMAN
FACTORS EXPERTISE IN HEALTH CARE 2
·
Human factors
experts use evidence-based guidelines and principles to design ways to make it
easier to safely and efficiently do things such as: (i) order medications; (ii)
hand off (hand over) information; (iii) move patients; and (iv) chart medications
and other orders electronically.
·
If these tasks
were made easier for the health-care practitioner, then they would be able to
provide safer health care.
·
These tasks
require design solutions that include software (computer order entry systems),
hardware (IV pumps), tools (scalpels, syringes, patient beds) and the physical
layout, including lighting of work environments.
·
The
technological revolution in health care has increased the relevance of human
factors in errors because the potential for harm is great when technology is
mishandled.
HUMAN
FACTORS ENGINEERING
·
Human factors
incorporates the human–machine interactions (including equipment design)
·
Human factors
include human–human interactions such as communication, teamwork and
organizational culture.
·
Human factors engineering
seeks to identify and promote the best fit between people and the world within which
they live and work
·
The workplace needs
to be designed and organized to minimize the likelihood of errors occurring and
the impact of errors when they do occur.
·
While we cannot
eliminate human fallibility, we can act to moderate and limit the risks.human
factors is about understanding human limitations and designing the workplace
and the equipment we use to allow for variability in humans and human performance.
·
Knowing how
fatigue, stress, poor communication and inadequate knowledge and skill affect
health professionals is important because it helps us understand predisposing
characteristics that may be associated with adverse events and errors.
14
15
HUMAN
FACTORS AND MEDICAL ERRORS
·
Errors can
occur during reception, processing, and interpretation of information
·
Humans inferior
to machines: unpredictable, unreliable, limited memory, lower speed of
information processing, distractible,
·
Humans superior
to machines: creative, self-aware,
imaginative and flexible in their thinking
·
Humans can
misperceive situations leading to errors
·
Human factors
that predispose to errors: illness,
medication, stress,alcohol, fatigue, emotion
THINGS
TO DO TO AVOID ERRORS
·
Do not rely on
memory, write it down read instructions before action
·
Make things
visible
·
Review and
simplify processes
·
Standardize
common processes and procedures
·
Routinely use
checklists
·
Decrease
reliance on vigilance: do not assume you will realize the error
SUMMARY:
WHAT IS NEEDED
·
Understanding
the interaction and interrelationships between humans and the tools and
machines they use.
·
Understanding
the inevitability of error and the range of human capabilities and responses in
any
·
given situation
is essential to knowing how application of human factors engineering principles
·
Can improve
health care.
SMALL
GROUP EXERCISES
Working
in groups of 5-6 students develop checklists for avoiding errors in the
following procedures
1.
Taking blood,
cross matching, and transfusing
2.
Preparing an
intravenous infusion with three drugs in powder form and administering the drug
3.
A skin
operation involving removing a leg vein and using it to graft a diseased
coronary artery
4.
Cannulation of
the femoral artery
CASE
STUDY No 1: Sandra, a 28-year-old woman, goes to see her obstetrician
complaining of a three-day history of foul-smelling vaginal discharge. Sandra
gave birth to a baby boy 10 days earlier. She required anesthesiology during the
delivery process. The obstetrician suspects a urine infection and prescribes a five-day
course of antibiotics.
·
Sandra returns
to see the obstetrician a week later with the same symptoms. She has completed
the course of antibiotics. Vaginal examination reveals tenderness at the
episiotomy site and some swelling. The obstetrician goes through Sandra’s case
notes in detail, looking particularly at the notes relating to the delivery and
at the swab count. The count has been documented in the case notes, and
verified by a second nurse. A further course of antibiotics is prescribed.
·
As the symptoms
persist, Sandra decides to seek a second opinion and goes to see a different obstetrician.
The second obstetrician admits her for an examination under anesthesia and
dilation and curettage (D&C). The obstetrician telephones the first
obstetrician of finding a swab left behind during packing of the episiotomy
wound and to advise him to inform his professional indemnity insurer.
·
Reference: Case
from the WHO Patient Safety Curriculum Guide for Medical Schools expert
consensus group. Supplied by Ranjit De Alwis, International Medical University,
Kuala Lumpur, Malaysia
CASE
STUDY No 2:
·
Suzanne’s
medical history included four caesarean sections in a 10-year period. The second
and third operations were held at hospital B and the fourth at hospital C.
·
Two months
after her fourth caesarean, Suzanne presented to hospital C suffering from
severe anal pain. A doctor performed an anal dilation under general anesthesia
and retrieved a surgical retractor from the rectum that
was 15 cm long by 2 cm wide, with curved ends. It was of a type commonly used by
New South Wales hospitals and the engraved initials indicated it came from
hospital B. The doctor thought that the retractor had been left inside Suzanne
after one of her caesareans and it had worked its way gradually through the
peritoneum into the rectum.
·
During her fourth
caesarean, the surgeon noted the presence of gross adhesions, or scarring, to the
peritoneum; whereas, no scarring had been seen by the doctor who had performed
the third caesarean two years earlier.
·
While it is not
known for certain what had occurred, the instrument was most likely to have
been left inside Suzanne during her third caesarean and remained there for more
than two years.
