Patient Safety 103: Human Factors and Safety

Skill=based errors

(e.g. forgetting keys or operating a door incorrectly, occur during automatic thinking.

Social Redundancy

(e.g.) Calling a patient after discharge to make sure he is taking medications as prescribed Confirming with a patient that she received nutrition counseling during her primary care visit Filling an order for congestive heart failure medication in the pharmacy, and double-checking that the hospital has implemented congestive heart failure protocol for the patient

Which of the following is an example of unconscious processing by the brain? A. Optical illusions B. Skipping a step on a checklist to save time C. Mistaking one drug for another because of look-alike packages D. A and C (Optical illusions AND mistaking one drug for another because of look-alike packages)

D. A and C (Optical illusions AND mistaking one drug for another because of look-alike packages) Rationale: Optical illusions and mistakes involving look-alike drugs and names reflect unconscious processing by the human brain. Unconscious processing is a fundamental part of human cognition that can lead to human error even when people are trying their best. Safe systems take these known characteristics of human cognition into account to help people do things the right way.

You're working in an outpatient clinic that recently started using an electronic health record (EHR). You are entering a prescription for an antibiotic into the EHR to treat Mrs. Jones's urinary tract infection. As you enter the order, a warning screen pops up saying that she has chronic kidney disease, and the medication dose should be adjusted based upon her last recorded creatinine level (a measure of kidney function). However, you know that Mrs. Jones's most recent creatinine level — recorded at a different clinic and therefore not available in your EHR — came back normal. When you attempt to move past the warning, the system will not allow you to proceed. Which of the following concepts does this scenario demonstrate? A. Technology can introduce unintended problems. B. Technology should facilitate how you do your work, not dictate it. C. Human beings must still be very present when interacting with technology to ensure its proper and effective use. D. All of the above

D. All of the above Rationale: All of the above is the best answer. In this case, the computer has information, but not all of the information. The system does not seem to allow for the fact that there will sometimes be additional information that caregivers must take into account. Instead, it tries to force caregivers to follow rigid rules. Remember: Human beings must still be very present when interacting with technology to ensure its proper and effective use.

At the end of your training session on your clinic's new EHR, you are handed a two-sided laminated card titled "Quick Start Guide." It provides step-by-step instructions for basic tasks such as entering orders and writing daily notes in the EHR. This is an example of: A. Automating carefully B. Simplifying C. Using forcing functions and constraints D. Avoiding reliance on memory

D. Avoiding reliance on memory Rationale: Checklists, such as the laminated guide, alleviate your reliance on memory to help make sure you perform a given process (which is not automated and relies on you) correctly. There is nothing forcing you to use this checklist, and it isn't simplifying the steps in the process — just helping you remember them.

Your hospital is implementing an electronic health record (EHR) and is teaching all staff how to use it. As you go through the EHR training, you notice that it takes five clicks to bring up the vital signs for a patient. In the past, when you wanted to see a patient's vital signs, you could simply look at the sheet of paper clipped onto the end of the bed. Which of the following likely needs to be improved about the new process to review vital signs? A. It needs to be standardized B. It needs to avoid reliance on memory C. It needs redundancies added D. It needs to be simplified

D. It needs to be simplified Rationale: A process that has a lot of steps — some of which seem unnecessary — is a prime target for simplification. This is especially true for commonly used processes, such as reviewing and recording vital signs.

Which of the following statements about redundancies within processes is always true? A. They are needlessly inefficient B. They remove the opportunity for error C. They require two people to do the work of one D. None of the above

D. None of the above Rationale: None of these statements is always true. In high-risk situations — such as the medication administration process — you may need redundancy to ensure safety. Although a typical redundancy involves one person checking the work of another, you can also use technology to "double check." It's important to keep in mind that it is possible for two people to make the same mistake and double checks can still allow the opportunity for error.

Manufacturers redesigned enteral tubing (tubing intended for oral administration) so that it could not be connected to intravenous tubing. A. Forcing Function B. Constraint

Forcing function Several years ago, there were many instances when a product intended for oral use was given to a patient intravenously. These incidents resulted in serious harm to the patient, sometimes even death. This simple change of making it so that the oral version could not be connected to intravenous tubing eliminated the opportunity for a mix-up.

Redundancy

a double check, when one person checks the work of another

Human factors engineering

An established science that uses disciplines such as anatomy, physiology, physics, and biomechanics to understand how people perform under different circumstances.

Alert fatigue

occurs when a person is exposed to a large number of frequent alarms [alerts] and consequently becomes desensitized to them

As a caregiver, which of the following common health IT issues would you be in the best position to help solve? A. Incomplete data entries into the computer B. Delays due to connectivity issues C. Out-of-date software D. None of the above

A. The best answer is incomplete data entries into the computer, which is a human-computer issue (as opposed to a computer issue). User feedback from caregivers is critical to improve the interfaces between computers and humans.

In the patient setting, concentrated electrolytes, which are lethal when administered undiluted, have been relocated from patient care units so that nurses must leave the unit to obtain them. A. Constraint B. Forcing function

A. Constraint Rationale: By making a nurse travel to another location to obtain concentrated electrolytes, organizations can restrict nurses from using the electrolytes without proceeding through the appropriate checks and reduce the possibility that someone will inadvertently and mistakenly administer an undiluted lethal dose. It is not impossible to obtain the product; it is just more difficult.

The first time you admit a patient using your health system's new EHR, you see a screen pop up as you are attempting to enter orders. At the top it says, "You must enter orders for DVT (blood clot) prevention before completion of this admission order set. Click here to complete this order." This pop-up box is an example of the use of: A. Forcing function B. Simplification C. Redundancy D. A and B (Forcing function AND Simplification)

A. Forcing function Rational: Forcing functions make it impossible to skip a task. Just as you cannot put a car into reverse unless your foot is on the brake, you cannot complete this particular admission order in this EHR unless you address the prevention of blood clots. This is not an example of simplification, as it actually adds a step. At the same time, it's not repeating a step, so it's not an example of redundancy.

Check your understanding: Which of the following is a skill-based error you might make while driving? A. You leave work and drive toward home, forgetting you meant to grab something at the store in the opposite direction. B. While driving to your friend's new home for the first time, you misinterpret directions from your GPS and take a wrong turn.

A. You leave work and drive toward home, forgetting you meant to grab something at the store in the opposite direction. Driving home from work is something you do all the time, relying on automatic thinking. Forgetting to drive to the store was a skill-based error.Meanwhile, driving somewhere for the first time would require more conscious attention and decision-making. In the example, you had the GPS giving you the information you needed, and you consciously applied the knowledge incorrectly: a rule-based mistake. (An example of a skill-based error involving GPS would be if you took a turn you knew you did not want to take because you were following the GPS instructions without paying attention to what you were doing.)

Knowledge of human factors can help health care workers avoid

Administering the incorrect medication because of look-alike medication names and packaging Ignoring a critical alarm because of exposure to too many false alarms Forgetting orders you gave in the middle of the night

flew the plane 30 miles past its destination in Hawaii into open ocean. Air traffic controllers tried to contact them nearly a dozen times during 17 minutes. An investigation found that one pilot's sleep apnea, which caused him to lose sleep at night and feel fatigue during the day, as well as long work hours, contributed to the incident.1 Can you identify the internal factors that contributed to the error in this scenario? A. Long hours B. Illness C. Fatigue D. Boredom

An illness and fatigue (and possibly boredom) were internal factors that contributed to the error. Long work hours were an external factor, related the individuals' environment, that contributed to the error. Fatigue is one of the most common physiologic factors that can lead to error in both automatic and controlled thinking. Ways that fatigue can impact an individual's performance and personality include. Reducing decision-making ability Prolonging response time Increasing lapses in attention Negatively affecting short-term memory Lessening ability to multitask Increasing irritability, moodiness, and depression Decreasing ability to communicate Scientists have studied fatigue as a contributing factor to errors in many high-risk industries.

Which of the following circumstances do you think warrant(s) a redundancy? A. Any process in health care B. A situation where a failure in the first step can result in serious harm C. A situation in which adding redundancy will save time D. A secondary system is needed in the event a first system fails

B and D (A situation where a failture in the first step can result in serious harm; A secondary system is needed in the event a first system fails. Rationale: Although not every process in health care requires a redundancy, it is important to have one when a primary system can fail and such failure would result in harm. By nature, redundancies add a little extra time, but they are worth it in high-risk situations when there is not a more effective option available for preventing errors.

Which of the following is a basic strategy for minimizing the opportunity for error in a process? A. Reducing reliance on technology B. Standardizing how the process is completed C. Trying harder to perform the process correctly D. A and C (Reducing reliance on technology AND Trying harder to perform the process correctly)

B. Standardizing how the process is completed Rationale: The science of human factors has helped us identify many design principles that can help prevent errors; standardizing processes is one such principle. Although we shouldn't be overly reliant on technology, technology can often be used to help prevent errors. Simply trying harder is not an effective error-prevention tactic.

Effective ways for addressing defects in the human-technology interface include: A. Providing in-person user training on using the technology B. Testing the technology in real-world situations C. Encouraging users to find workarounds D. All of the above

B. Testing the technology in real-world situations Rationale: Once designed, actual users should test technology in real-world situations. If users don't test the technology, then the possibility of introducing a faulty system goes up, which additional training would not address. Workarounds can lead to serious error; you should view them as a symptom of a poorly designed or overly complex system

Which of the following statements about bar-cording systems is true? A. They typically offer few benefits and merely promote workarounds. B. They can completely prevent medication errors. C. They can help providers keeps track of laboratory specimens, identify medications and medical equipment, and identify patients. D. B and C (They can completely prevent medication errors AND They can help providers keeps track of laboratory specimens, identify medications and medical equipment, and identify patients.)

C. Rationale: Bar-coding systems can help identify medications and match them to the correct patient, as well be used to label and track laboratory specimens, identify medical equipment, and identify patients. Despite these significant benefits, bar-coding systems have potential flaws, and can promote workarounds if not designed properly.

You enter a medication order in your hospital's EHR, and a warning screen pops up saying that your patient's medication dose should be adjusted based upon her last lab results. However, you know that the patient had a lab draw more recently — recorded at a different clinic and therefore not available in your EHR — that showed different values. When you attempt to move past the warning, the system will not allow you to proceed. What does this block best exemplify? A. How technology can be used to make patient care safer B. How technology can be used to make care more efficient C. How technology that dictates your work — rather than facilitates it — can introduce unintended problems D. A and B (How technology can be used to make patient care safer AND How technology can be used to make care more efficient)

C. Rationale: In this case, the system appears to be problematic because it does not allow for the fact that there will sometimes be additional information that caregivers must take into account, and tries to force caregivers to follow rigid rules. A situation of this kind is inefficient and likely to result in a workaround that may make patients less safe.

Which of the following is a basic strategy for minimizing the opportunity for error in a process? A. The human brain can only remember approximately 22 pieces of information at once. B. Completing checklists gives people a sense of accomplishment. C. Checklists prompt providers to remember and appreciate the importance of tasks. D. None of the above; checklists should not typically be used because they insult the intelligence of providers and staff.

C. Checklists prompt providers to remember and appreciate the importance of tasks. Rationale: The science of human factors has helped us identify many design principles that can help prevent errors; simplifying processes is one such principle. At its most basic level, simplifying involves taking steps out of a process (for example, this could mean automating a manual part of the process). If something is too complex, users may find a simpler but more dangerous way to achieve the end result (a "workaround"), and it can lead to significant problems.

Do you remember the nurse, Karen, from the previous lesson? She connected the wrong cord to a heart-monitoring machine, and it killed a four-year-old girl. Sadly, her story was true. But we can do better.If you were redesigning the environment, processes, and systems within which Karen worked, what design strategy would you implement to prevent her from connecting the electrical cord to the heart rate monitor tomorrow? What strategy would be the best option to prevent someone else from making Karen's error in the future? A. Create a checklist B. Add a constraint C. Create a forcing function D. Add redundancy

C. Create a forcing function Rationale: Although any of these solutions could possibly help, the best option is to create a forcing function. Redesigning the equipment so that the wrong cords are impossible to connect eliminates the chance for a human being to accidentally do the wrong thing.

You're caring for a patient with diabetes who was admitted to your hospital with an elevated blood glucose level. She is on an insulin pump that is programmed to deliver one unit of insulin per hour through her intravenous (IV) line. Which of the following is a risk of this technology? A. The pump is dictating rather than facilitating your work. B. The pump could malfunction. C. There is no risk associated with the pump. D. A and B (The pump is dictating rather than facilitating your work AND The pump could malfunction)

Rationale: Although the pump helps facilitate your work by automating the process of delivering a precise amount of insulin at regular intervals, there is always some chance it could malfunction. Remember, human beings must still be very present when interacting with technology to ensure its proper and effective use.

Three Types of Errors

Skill-based Rule-based Knowledge-based

Automatic thinking

This is rapid, effortless thought, during which we are vulnerable to what experts call skill-based errors. Skill-based errors comprise errors of execution (which Reason called slips) or errors of memory storage (which Reason called lapses).

Controlled thinking

This is when we consciously, often slowly, solve problems and make decisions. This is when errors of planning can occur. James Reason called these errors mistakes, and said they could be rule- or knowledge-based.

Electronic medical and health records (EMRs or EHRs)

are digital patient files that allow providers to access medical information at a variety of facilities, track health information over time, easily identify patients who are eligible for preventive visits and screenings, monitor key health indicators such as blood pressure, and improve the quality of care by understanding the patient population's health as a whole

Internal causes of error "endogenous" causes Internal factors that can cloud our judgment and thought processes include: Limited memory capacity Fatigue Stress, hunger, and illness Language limitations Hazardous attitudes

are factors related to the individual (as opposed to his/her environment), which include both psychological and physiological states.

External causes of error "exogenous" causes External factors that can impact performance include: Noise, heat, and light Long work schedules Inadequate training Poorly designed rules or procedures Interruptions and distractions Language barriers

are factors related to the individual's environment

Forcing functions

are like constraints, but they make it impossible to do a task incorrectly.

Which of the following types of errors is associated with controlled thinking? A. Errors of memory storage B. Errors of planning C. Skill-based errors D. A and C (Errors of memory storage AND Skill-based errors)

b

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you guess was the biggest contributor to this error? A. The nurse deliberately ignored protocol. B. The nurse was prone to error because she was tired. C. The nurse's training was out-of-date. D. The nurse had become complacent and stopped trying hard.

b Rationale: The nurse was most likely fatigued after a double shift, which made her prone to error. We cannot sustain performance by merely trying hard and paying attention, and fatigue can affect performance no matter how hard you try or how excellent your training may be. When you are fatigued, you need processes that help prevent you from making an error, or mitigate the effects of an error if you do make one.

Human factors is the study of: A. Interactions among humans B. Interactions between humans and machines C. Interactions between humans and the environment D. All of the above

d Rationale: Human factors is an established science that uses many disciplines to understand how people perform under different circumstances. This engineering discipline deals with the interface of people, equipment, and the environment.

At the end of a double shift, an experienced nurse with an excellent track record gives a medication to the wrong patient. Based on human factors principles, what would you recommend as the best way to prevent the same error from recurring? A. Ensuring staff training is up-to-date B. Incentivizing nursing staff to remain vigilant C. Improving medication administration processes D. A and B (Ensuring staff training is up-to-date AND Incentivizing nursing staff to remain vigilant)

c Rationale: The best answer is to improve medication administration processes. The nurse was most likely fatigued after a double shift, which made her prone to error. We cannot sustain performance by merely trying hard and paying attention, and fatigue can affect performance no matter how hard you try or how excellent your training may be. When you are fatigued, you need processes that help prevent you from making an error, or mitigate the effects of an error if you do make one.

You're caring for a patient with diabetes who was admitted to your hospital with an elevated blood glucose level. She is on an insulin pump that is programmed to deliver one unit of insulin per hour through her intravenous (IV) line. How does this technology help make her care safer? A. The pump eliminates the need for providers to be involved in her care. B. The pump eliminates the possibility of a medication error. C. The pump helps automate a complex care process D. All of the above

c Rationale: The pump automates the complex process of precisely administering insulin at regular intervals, helping make care safer for the patient. However, there's the chance the pump could malfunction, and providers dictate dosing decisions, so errors could still occur. Providers must always be present to ensure proper and effective use of technology.

When attempting to decrease the risk of error, it's important to use human factors principles because: A. If you understand human factors principles, you can always justify using the latest technology at the bedside. B. If you understand the factors that cause people to make mistakes, you can hire safer providers. C. If you understand the factors that affect human performance on critical tasks, you can design a safer system. D. If you understand human factors principles, you can ensure your system is perfectly safe.

c Rationale: Understanding how factors that affect human performance (such as fatigue, stress, and poor lighting) affect work and detract from one's ability to execute a safety-critical task (such as administering a medication, filling a prescription, or writing an order) can help you design processes and systems in ways that make them safer.

Which of the following is the best example of using technology to improve safety and prevent errors? A. Implementing redundancies, in which providers double-check each other's electronic inputs B. Providing inpatients with electronic tablets so that they can keep in better touch with the outside world C. Giving nursing assistants electronic tablets to ensure there's no delay in recording patients' vital signs D. Switching to an electronic health record (EHR) platform that is of comparable quality but lower cost

c Rationale: Using tablet technology to allow nursing assistants to record vital signs immediately is an example of using technology to make work safer. When vital signs are recorded much later than they're observed, the opportunities for error increase. Giving patients tablets may improve their inpatient experiences, but isn't as likely to prevent errors. Switching to a lower cost EHR platform may make good business sense, but that decision won't directly affect patient safety. If providers are checking each other's work that can make care safer, but it's a social redundancy rather than a technology-based redundancy.

Which of the following factors can increase human risk for error? A. Predisposing mental and physiological states (e.g., fatigue, stress, dehydration, hunger, and boredom) B. Factors that directly enable decision making (e.g., perception, attention, memory, reasoning, and judgment) C. Factors that directly enable decision execution (e.g., communication and being able to carry out the intended action) D. All of the above

d Rationale: The best answer is all of the above. All three choices include factors that impact human performance and can increase risk for error.

Bar-coding systems

can be used to correctly and consistently identify things and track their movement. In health care, they help identify medical personnel for security reasons using personal identification badges. Medication bar-coding systems can help identify medications and match them to the correct patient. This helps with effective medication administration and inventory control. Bar-coding systems can also be used to label laboratory specimens, identify medical equipment, and identify patients

Intravenous medication (IV) infusion pumps

can control how quickly a medication is administered. The latest infusion pump technology includes the ability to compare the dose of a medication programmed by a nurse into the computer with a predetermined appropriate value. If the programmed dose exceeds the limit of the predetermined value, the computer will alert the user.

Pharmacy computer programs

can help track medication doses and inventory, and now also offer a number of clinical interaction features, including drug interaction testing, therapeutic duplication checks, dose checks, and impact of laboratory values on dosing.

Cognitve errors

contribute to improper testing, unnecessary treatments, and missed diagnoses.

Which of the following types of errors is associated with automatic thinking? A. Errors of memory storage B. Errors of planning C. Errors of execution D. A and B (Errors of memory storage AND Errors of planning)

d Rationale: Automatic thinking is rapid, effortless thought, during which we are vulnerable to what experts call skill-based errors, which include errors of execution or memory storage. In comparison, controlled thinking is when we consciously, often slowly, solve problems and make decisions. This is when errors of planning can occur, also known as "mistakes."

Constraint

defined as the state of being checked, restricted, or compelled to avoid or perform some action. Constraints can be helpful to keep predictable errors from causing harm. Constraints can be problematic in unpredictable environments when people need to be able to react quickly.

Check off the human-computer problems on this list: A. The software was not functioning properly B. The software was not up to date. C. Data were entered incorrectly into the electronic record due to multiple records being open. D. The user ignored or overrode an alert. E. The network was down or slow. F. Data were not displaying properly in the system. G. Data were not entered into the system H. A patient was not identified properly, and all clinical information was entered into the wrong record.

h c d g

Computerized prescriber order entry systems (CPOEs)

provide alerts for drug interactions and therapeutic duplication, thus reducing the reliance on the human memory. They also eliminate confusion from poor handwriting and can automatically connect with laboratory systems to check for lab values that may impact drug doses

Simplification

reduces complexity; are there steps in the system, are there things, that can be eliminated because they really don't bring value or can be done in some other way.

Standardization

reduces variation; what is the best way known to achieve those outcomes that we want to achieve?