Improving Patient Safety using a Human Factors and Ergonomic approach Debbie Clark Deborah.Clark@yhahsn.nhs.uk

1 in 10 patients will suffer adverse events There is a problem. 1 in 10 patients will suffer adverse events 50% of the events were preventable. 33% of adverse events led to moderate, or greater disability, or death DH (2000); Vincent (2006) What is an adverse event?

Healthcare is increasingly complex. Human Fallibility Healthcare is increasingly complex. Fallibility makes healthcare professionals (as humans) prone to error. Systems that depend on perfect human performance are inherently flawed. Communication failure Lack of effective training Memory lapse Inattention Poorly designed equipment Exhaustion, fatigue Ignorance Noisy working conditions Other personal and environmental factor

Count the F’s in the sentence. FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS. its easy to get it wrong- especially under pressure of time... give 7 or 8 seconds to count... most will say 3 as they don't count of (its pronounced 'ov', so their brains tell them its a 'v' not an 'f')... this happens when they miss an PO has been changed to IV or vice versa

FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS.

Please be as careful as possible as you read this! Aoccdrnig to rscheearch at an Elingsh uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, olny taht the frist and lsat ltteres are at the rghit pcleas. The rset can be a toatl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae we do not raed ervey lteter by ilstef, but the wrod as a wlohe. Think about this the next time you check a bag of blood or an ampoule. And by the way – did you notice the duplicate “as” in the heading? Get some pictures of medication boxes # In own areas look through cupboards – risk areas that you could improve? Second check When I worked in the emergency theatre (maybe long ago, perhaps far away) I came to work on a Monday and discovered in the drug cupboard a box of 10ml ampoules of 1/1000 adrenaline, the only way they looked any different to the usual 1/10,000 was the missing zero. We have never stocked this presentation which had come from pharmacy by mistake. Three ampoules were gone. So either 3 had been given as 1/1000 or 3 people had noticed and not done anything about it. So we cannot trust our eyes, can we trust our ears? (Actually someone might notice words with less than 4 letters are spelt correctly) 6

Link Can we trust are ears? Click picture to start

Humans will make mistakes What are the human errors which commonly feature in healthcare failings: Communication failure Lack of effective training Memory lapse Inattention Poorly designed equipment Exhaustion, fatigue Ignorance Noisy working conditions Other personal and environmental factor

Swiss Cheese and Front line Staff Where do 'you' frontline staff fit on this model? This is why you are important. Although you are most at risk of causing a pt. safety event you are also most likely to be the one who prevents the error occuring. We all need to see ourselves as managers of safety. We need to train you as individuals to perform at your best in teams! No longer considered good enough to teach you technical skills without addressing the non technicla aspect of the things we do too. Reason (1990)

Error is not real issue, the issue is that we Error is not real issue, the issue is that we allow error to cause harm... 1 30 300 Death or Serious Harm Moderate Harm Near miss Heinrich (1931)

Anyone for...Clinical Human Factors "Enhancing Clinical Performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities and application of that knowledge in clinical settings" Catchpole (2011) Making it easy to do the right thing Human centred design

SHELL (Hawkins & Orlady, 1993)

Human Factors Principles Individual Error is normal Performance is variable System

Individual performance Stress Fatigue Hunger Late Anger Human Factors Individual performance Stress Fatigue Hunger Late Anger Team performance Communication Sharing mental models Decision making Good day Average day Bad day Performance shaping factors (PSF)

Non-Technical Skills We make an assumption that if we give individuals the technical skills, they will be able to efficiently use these skills when working together in teams (GAT 2009) 70 -80 % of error due to a failure in team work and communication.

Non-Technical Skills Communication Situational Awareness Feedback SAFETY Decision Making Behaviour Leadership / Followership

Error chain... Serious case reviews Missed opportunities Communication breakdown Inaccurate Situation Awareness Poor decision making Unworkable rules and procedures System change over

Error chain Patient Harm Start of the error chain Staff sickness: extra workload Distraction - Relatives -Drs rounds Missed breaks Stress High Cognitive load Busy Fatigue Start of the error chain Error chain

Change to tallman lettering No Harm Change to tallman lettering Barrier Cross-check Stress Fatigue Start of the error chain Error chain- broken

Using Human Factors to increase safety... We have to accept that the vast majority of people come to work to a good job Mistakes are usually caused by ineffective systems not bad people Systems should be deigned so that it is easy to do the right thing. Creating a culture where human error is seen as a source of important learning. This also means taking personal responsibility for safety, whoever we are, where ever we are.

Change Yourself?

Change the system? Standardise Simplify Checklist Automate if relevant Reduce distractions Team training

Any Questions?

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