1. Usability and Human Factors Human Factors and Healthcare Lecture b This material (Comp15_Unit4b) was developed by Columbia University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 1U24OC000003.

2. Human Factors and Healthcare Learning Objectives 2 Describe the different dimensions of the concept of human error (Lecture b) Describe a systems-centered approach to error and patient safety (Lecture b) Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

3. Patient Safety http://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_license 3 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Healthcare discipline emphasizes reporting, analysis, and prevention of medical error. Landmark Report: Institute of Medicine (1999) Magnitude of the problem not known

4. Harvard Medical Practice Study 4 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Reviewed medical charts of more than 30,000 patients admitted to 51 acute care hospitals in New York State in 1984 3.7% of the cases, an adverse event led to prolonged admission or disability 69% of injuries were caused by errors 27.6% of adverse events due to negligence 13.6% led to patient deaths Substantial injury to patients from medical management many injuries result from substandard care

5. Why do Errors Happen? 5 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Error is the failure of a planned sequence of mental or physical activities to achieve its intended outcome when these failures cannot be attributed to chance Inclination to blame somebody –Who is responsible? Often the person closest to the failure becomes the one who gets blamed Can we isolate a single cause? “When human error is viewed as a cause rather than a consequence, it serves as a cloak for our ignorance” (Henriksen et al, 2008). Systems-centered approach: –Latent Conditions and Active Failures (Reason, 1997)

6. Active Failure Occur at the level of the frontline operator –Effects are felt immediately In health care, active errors are committed by providers (e.g., nurses, physicians, pharmacists) who are actively responding to patient needs at the “sharp end” 6 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

7. Latent Conditions (Reason, 1990) 7 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Latent Conditions are enduring systemic problems that lay dormant for some time, combine with other system problems to weaken the systems defenses and make errors possible Poor interface design Communication breakdown Gaps in supervision Incorrect equipment installation Hidden software bugs Fast-paced production schedules Unworkable procedures Extended work hours Staffing problems Inadequate training Aloof management Absence of a safety culture

8. Hindsight Bias 8 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Collected data is evaluated against the negative outcome Difficult to recreate the situational context, stress, shifting attentional demands & competing goals Retrospective after-the-fact analysis of human error is bias prone Distorted view of factors contributing to the incident or accident Hindsight bias masks the dilemmas, uncertainties, & demands

9. Space Shuttle Challenger Disaster http://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.html 9 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Space shuttle exploded on takeoff in 1986 killing 8 crew members Cause: O-ring seal in rocket booster failed at liftoff Multiple faults including unanticipated cold weather, brittle O-ring seals, communication problems between NASA and contractors, etc. Latent errors went unrecognized

10. Deepwater Horizon Explosion http://www.flickr.com/photos/skytruth/4733160839/sizes/l/ 10 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

11. Reason “Swiss Cheese” Model of Error Reason, J (2000). 11 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Adverse Event Organization Influences Unsafe Supervision Preconditions for Unsafe Acts Active Failures Latent Failures Latent Failures Latent Failures

12. Slips: –Incorrect execution of a correct action sequence Errors when routine behavior is misdirected or omitted Mistakes: –Correct execution of an incorrect action sequence Errors in judgment, perception, inference or interpretation Human Errors 12 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

13. Knowledge-Based –Faulty conceptual knowledge –Incomplete knowledge –Biases and faulty heuristics –Incorrect selection of knowledge –Information overload Rule-Based –Misapplication of good rules –Encoding deficiencies in rules –Action deficiencies in rules –Dissociation between knowledge and rules Mistakes 13 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

14. Example: Error One Description of the environment/case study information: –Mr. B is a 45 year old male being treated for dehydration secondary to nausea, vomiting and diarrhea –Mr. B has been in the Intensive care Unit (ICU) for 4 days receiving intravenous fluids via an IV catheter in his right forearm –As Mr. B stabilizes, the physician orders to start P.O. fluids (fluids by mouth) and discontinue the IV fluids Note, the order is to discontinue the IV fluids, not the IV Typically, the RN will stop the IV fluid and convert the IV to a saline lock that may be used for intermittent infusions as necessary 14 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

15. Example: Error One (cont.) 15 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b The RN removed the entire IV catheter when it should have been converted to a saline lock Identification of the error: Slip: automatic use of a well-learned routine that overrides the current intended activity RN intended to convert the IV to a saline lock; however, she discontinued the entire access Classification of the error:

16. Example: Error Two Mr. Jones is assigned to a team of nurses for the dayshift One nurse responsible for giving medication to patients on the team Other nurse responsible for all assessments & treatments Mr. Jones complains of pain to the treatment nurse Rather than delay the pain medication waiting for the medication nurse, treatment nurse obtains narcotic and administers it to Mr. Jones Treatment nurse forgets to document on medication record that she gave Mr. Jones some Demerol for pain When making rounds, medication nurse asks Mr. Jones if he is in pain Mr. Jones again replies yes Medication nurse reviews medication record -- no documentation of pain medication given She medicates Mr. Jones with Demerol (again) Within 1 hour, Mr. Jones is lethargic & has respiratory depression He has to be transferred to ICU for closer monitoring due to Demerol overdose 16 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

17. Example: Error Two (cont.) 17 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Classification of the error: –Repetition of action slip: repetition of a correctly performed action –Each RN medicated the patient according to the physician's orders; however, due to the error of "no documentation" the patient received a repeated dose of Demerol Repetition of action slip: repetition of a correctly performed action Each RN medicated the patient according to the physician's orders; however, due to the error of "no documentation" the patient received a repeated dose of Demerol Classification of the error:

18. Interdependence of The Health Care System “Healthcare is composed of a large set of interacting systems - paramedic, and emergency, ambulatory, inpatient care and home health care; testing and imaging laboratories; pharmacies that are connected in loosely coupled but intricate networks of individuals, teams procedures, regulations, communications, equipment and devices that function with diffused management in a variable and uncertain environment” (p 158) »Kohn et al, (2000)To Err is Human 18 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

19. Systems Approach to Adverse Events in Health Care 1.1 Chart: (Henriksen, 2008) 19 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b External Environment Knowledge Base Demographics New Technology Gov’t Initiatives Economic Pressures Health Care Policies Public Awareness Political Climate Management Patient Load Staffing Organization/ Safety Culture Accessibility of Personnel Leadership Involvement Physical Environment Lighting Noise Workplace Layout Distractions Human-System Interface Medical Devices Equipment Location Controls and Displays Paper/electronic Charts Distractions Org/Social Environment Authority Gradients Group Norms Communication/ Coordination Local Procedures Work Life Quality

20. Systems Approach to Adverse Events Continued 20 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Nature of the Work Treatment Complexity Workflow Individual vs. teamwork Competing Tasks and interruptions Physical/Cognitive Requirements Individual Characteristics Knowledge/Skills Experience Physical Capabilities Alertness/fatigue Motivation/Attitude Cultural Competency Acceptable Performance Sub-Standard Performance Predictable Adverse Event 1.2 Chart: (Henriksen, 2008)

21. 1.3 Chart: (Zhang et al, 2004) 21 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b Near Miss Boundary Normal Routine Adverse Event Report Boundary Violation of consensual bounds of safe practice Error recovery: Detection and correction of violation Time Time Course of Medical Error

22. Human Factors and Healthcare Summary – Lecture b Patient Safety and human error Reason model of error –Slips and mistakes –Knowledge vs rule-based mistakes Systems approach to medical error Next lecture: Workload, medical devices and mental models 22 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

23. Human Factors and Healthcare References – Lecture b Reference Carayon, P. (Ed.). (2007). Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ: Lawrence Erlbaum Associates. Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding Adverse Events: A Human Factors Framework. In H. R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 84-101). Rockville, MD: Agency for Healthcare Research and Quality Horsky, J., Kaufman, D.R., Oppenheim, M.I. & Patel, V.L. (2003). A framework for analyzing the cognitive complexity of computer-assisted clinical ordering. Journal of Biomedical Informatics, 36, 4-22. Kaufman, D. R., Pevzner, J., Rodriguez, M., Cimino, J. J., Ebner, S., Fields, L., et al. (2009). Understanding workflow in telehealth video visits: Observations from the IDEATel project. Journal of Biomedical Informatics, 42(4), 581-592. Kaufman, D.R. & Starren, J. B. (2006). A methodological framework for evaluating mobile health devices. In the Proceedings of the American Medical Informatics Annual Fall Symposium. Philadelphia: Hanley & Belfus. 978 Kaufman, D.R., Patel, V.L., Hilliman, C., Morin, P.C., Pevzner, J, Weinstock, Goland, R. Shea, S. & Starren, J. (2003). Usability in the real world: Assessing medical information technologies in patients’ homes. Journal of Biomedical Informatics, 36, 45-60. Reason, J.T. (1997) Managing the risks of organizational accidents. Ashgate Pub;ishing, Aldershot, UK. Reason, J.T. (1990) Human Error. Cambridge University Press, Cambridge. Kohn, L.T., Corrigan, J., and Donaldson, M. (2000). To Err is Human. Institute of Medicince, National Academy Press. Washington, Dc. 23 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b

24. Human Factors and Healthcare References – Lecture b Images Slide 3: Retrieved on September 10th, 2010 from http://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_licensehttp://www.flickr.com/photos/andyde/4762081047/sizes/l/#cc_license Slide 9: Retrieved on September 10th, 2010 from http://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.htmlhttp://grin.hq.nasa.gov/ABSTRACTS/GPN-2004-00012.html Slide 10: Retrieved on September 10th, 2010 from http://www.flickr.com/photos/skytruth/4733160839/sizes/l/http://www.flickr.com/photos/skytruth/4733160839/sizes/l/ Slide 11: Reason J (2000). Human error: models and management. BMJ, 320:768-70 Charts, Tables and Figures 1.1 & 1.2 Chart: Henriksen, K., Dayton, E., Keyes, M. A., Carayon, P., & Hughes, R. (2008). Understanding Adverse Events: A Human Factors Framework. In H. R.G. (Ed.), Patient Safety and Quality: An Evidence-Based Handbook for Nurses (pp. 84-101). Rockville, MD: Agency for Healthcare Research and Quality 1.3 Chart: Zhang, J., Patel, V. L., Johnson, T. R., & Shortliffe, E. H. (2004). A cognitive taxonomy of medical errors. J Biomed Inform, 37(3), 193-204. 24 Health IT Workforce Curriculum Version 3.0/Spring 2012 Usability and Human Factors Human Factors and Healthcare Lecture b