Breakfast With Quality Chief

CONFLICT OF INTEREST Disclosure I do not have affiliation (financial or otherwise) with a pharmaceutical, medical device or communication and event planning company

What About Patient Safety ? It is not : What most of us were thinking about 10 years ago What ‘we have always done’ It is : The most significant change in the healthcare system in over a century A new applied science It has forever changed the face of modern healthcare

Why Do Adverse Events Happen? In any system or organization that involves humans, error is inevitable because there is a wide variation in performance both within and between people. Evidence is accumulating that some human dispositions towards error are hard-wired. Only a small proportion of error is egregious. Ambient conditions and systemic design increase the likelihood of error. Error has been described as the ‘essential friction’ within all systems.

% Positive Responses from: A Culture of Safety % Positive Responses from: Pilots Medical Is there a negative impact of fatigue on your performance? 74% 30% Do you reject advice from juniors? 3% 45% Is error analysis system-wide? 100% Do you think you make mistakes? Easy to discuss/report mistakes? 56% *Sexton JB, Thomas EJ, Helmreich RL, Error, stress and teamwork in medicine and aviation: cross sectional surveys. BrMedJour, 3-18-2000.

Human Factors Humans are poor multi-taskers. Drivers on cell phones have 50% more accidents, 25% of traffic accidents are “distracted drivers”. Interruptions and distractions increase error rates. Humans need very formal cues to get back on task when interrupted and distracted.

Human Factors Fatigue Leonard, Michael MD. (Nov 2005). Safer Healthcare Now Presentation

Understanding Harm And No Harm Events

How to Apply Human Factors? Reports prioritizing recommendations based needs & identifying improvements to: Implement now Implement later Implement when/if cost & feasibility permit Based in part on a graphic from http://humanisticsystems.com/2014/09/27/systems-thinking-for-safety-ten-principles/

What is Human Factors?

How to Apply Human Factors?

Key Steps In Decision Making (DODAR) Explanation D-Diagnosis What is the problem ? O-Options What are the options ? D-Decision What are we going to do ? A-Assign tasks Who does what ? R-Review What happened / what are we going about it ?

Swiss Cheese Model (Close the holes or add a layer) Training in Clinical Human Factors Skills

Seven Steps to Patient Safety Lead and support your staff Foster a culture of safety Promote reporting Involve patients and the public Implement solutions to reduce / avoid harm Learn and share safety solutions Integrate your safety management activity

Rationale for Collaboration Many issues are both human factors and safety related Safety and HF practitioners have different viewpoints but shared goal of safe and effective operation. Human factors issues results in : Increase likelihood that safety concerns are designed to begin with Increase likelihood that issue will be fixed in a future build

Conclusion Accept that accidents are inevitable and failure will occur Accept that impact of failure can be minimized Promote a safety culture Listen to and support front-line workers Establish a framework that recognizes costs of failure and benefits of reliability Involve managers in communicating overall picture

Breakfast With Quality Chief, through understanding patients safety and strategy to improve patient safety Thank You DR AISHA ALADAB Consultant , Pulmonary and Sleep Medicine CCITP Faculty IHI Fellow Improvement Advisor