1. Breakfast With Quality Chief

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

3. 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

4. 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.

5. % 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,

6. 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.

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

8. Understanding Harm And No Harm Events

9. 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

10. What is Human Factors?

11. How to Apply Human Factors?

12. 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 ?

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

14. 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

15. 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

16. 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

17. 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