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Considering the Human Factors in Patient Safety
PATIENT SAFETY
Considering the Human Factors in Patient Safety Jacqueline Ross, MSN, RN, CPAN
THE INSTITUTE OF MEDICINE’S report To Err Is Human: Building a Safer Health System highlighted that more than 98,000 patients die each year in United States hospitals because of human error.1 Although this statistic is alarming, it is also important to highlight the fact that adverse events also lead to poor outcomes. Those poor outcomes correlate to longer recovery and hospital stays. A medical error can arise from various causes such as an error in execution (the action was not completed as planned) or an error in planning (the wrong plan was used). In addition, many errors can be termed as near misses in that no harm occurred, but there is a factor that needs to be considered. When an error does result in an injury, then it is termed an adverse event. The Institute of Medicine’s report placed an emphasis on understanding how adverse events and near misses occur in the hospital setting and having a better appreciation for what adverse events can be avoided.1 Their emphasis is on learning more about what is termed human factors.
events within the hospital was done more on an individual, risk management basis, and often lacked a clear understanding of the complexity surrounding the adverse event.3 Root cause analyses were used to identify causes of errors with sentinel events; however, these reports focused on a specific event and often overlooked the deeper system issues that required change.2 The focus now must shift to a culture of safety that embraces an open flow of information and the ability to learn about vulnerabilities within the system. It is important to note that errors are based on unintentional actions, not planned actions. With retraining, the focus is on planned behavior, overlooking the unintentional actions leading to the error. The reality is that in any systems involving human interaction, human factors are present. The challenge is bringing those specific factors to the surface because most errors are multifactorial. Highlighting patterns that can lead to injury requires a better appreciation of how humans interact in routine and challenging situations.
Human factors have been studied more frequently in areas outside health care, eg, aviation, military, and nuclear power plants. In his book, Managing the Risks of Organization Accidents and Human Errors, Reason2 notes that the analysis of human factors is the study of the interaction of equipment and individuals and the variables that can affect the outcome. Humans work within systems that may be flawed, and these flaws contribute to error. Complexity and interdependencies within organizational structure are acknowledged, and it is through the better understanding of these factors that errors can be diminished.
When examining errors, Reason2 and Drew et al3 stated that there are two elements that contribute to human errors: latent and active factors. Active factors are more common and are the actions or inactions of individuals. Active factors appear to lead to the error happening, and are typically unique to the situation, having immediate effects. Active factors can include2,3:
Health care, for the most part, was slow to respond to how human factors influenced errors. The old focus was reactive and focused on placing blame. Dealing with adverse Jacqueline Ross, MSN, RN, CPAN, is the ASPAN Director for Research, and is a Perianesthesia Nurse Consultant and Patient Safety Analyst with TDC, Columbus, OH. Address correspondence to Jacqueline Ross; e-mail address: [email protected]. Ó 2009 published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses. 1089-9472/09/2401-0008$36.00/0 doi:10.1016/j.jopan.2008.11.003 Journal of PeriAnesthesia Nursing, Vol 24, No 1 (February), 2009: pp 55-56
A lapse, such as not using a checklist, which leads to forgetting an important step in a process or an overreliance on memory. A slip, which refers to doing the correct action, but doing it incorrectly. Slips involve performance issues. Mistakes, which are the result of incorrect understanding of the situation, such as a wrong-site procedure. Mistakes involve decision-making; individuals choose the wrong action. Not following procedures, such as poor hand washing or verifying a patient’s name before giving a medication. Active factors are the easiest to identify because they tend to be the final product of a series of events culminating in the error. 55
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The latent factors are harder to detect and are more related to overall organizational policy or those arising from outside the organization such as regulatory issues. Latent factors are present in all organizations and are reflected through poor communication, policies, heavy workload, poor management skills, and overall organizational culture.2,3 Examples of latent factors that have received a lot of attention are medications that are packaged similarly and medications that sound alike. Often, latent factors are not evident until an active failure occurs that leads to an adverse event, and one latent factor can lead to multiple active factors and injuries.2 Reason and Drew et al’s model of error2,3 postulates that latent factors such as organizational process and management practices lead to error-producing conditions. Latent factors can be viewed as the contributory factors involved in the error. These latent conditions could lead to active failures such as mistakes, violations of policies, and lapses. All systems contain built-in defenses, but if for some reasons these defenses fail, then an adverse event occurs. Therefore, it is essential to have a better understanding of the latent factors.2,3 A focus on examining devices is important because the United States Food and Drug Administration’s Center for Devices and Radiological Health estimated that about one third of the incident reports received annually are related to an inattention to human factors when designing the device.4 Medical devices are often complex, are used under stressful conditions, and individuals who use the device may think differently than the designers of the device.4 In fact, human factors were considered in the design of anesthesia machines so that canisters of inhaled anesthetics cannot be switched with the oxygen canisters.
Unfortunately little research has been done in the perianesthesia areas on human factors. Some research in the intensive care unit (ICU) settings has been conducted on devices and human factors. One study3 focused on therapeutic and monitoring devices in the ICU. When examining the subjective assessments of ICU nurses, the nurses identified the most important error-producing conditions as low signal-to-noise ratio, unreliable instrumentation, operator–designer mismatch, and shortage of time. Drew and others3 also inquired about how frequently errors occurred in the ICU, and the results indicated that errors were frequent, with a mean of 6.35 (9point scale, with 9 indicating higher amount of errors perceived). These device issues may lead to nurses questioning the accuracy of monitoring readouts. Are there similar concerns in the perianesthesia areas? Unfortunately, many human factors remain unknown, especially in the perianesthesia areas. It is only through ongoing reporting of near misses and adverse events that the complexity of latent factors can be highlighted and adverse events eliminated. Many institutions have instituted mandatory and/or voluntary medication error reporting systems, but it remains unclear if these systems are being used by all health care providers. The reporting systems should also expand to include more than medication safety. The culture of blame may be more difficult to change. Every member of the organization can play a part in changing this culture of blame. Investigate what systems may be in place within your organization. Encourage your leadership to begin a better assessment of those latent factors that may be lurking. One initial step may involve assessing the attitudes of the health care team to reporting near misses and errors. Education may be required. Moving to a culture of safety is essential in decreasing the incidence of adverse events.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. Reason J. Managing the Risks of Organization Accidents and Human Errors. Hampshire, England: Ashgate Publishing Limited; 1997. 3. Drew F, Muster A, Samore M. Advances in Patient Safety: New Directions and Alternative Approaches, vol. 1-4. AHRQ Publication,
Nos. 08-0034 (1-4). Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ahrq.gov/qual/advances2/ Accessed November 24, 2008. 4. Kaye R, Crowley J. Medical Device Use-Safety: Incorporating Human Factors Engineering into Risk Management. Washington, DC: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health; 2000.
Considering the Human Factors in Patient Safety Jacqueline Ross, MSN, RN, CPAN
THE INSTITUTE OF MEDICINE’S report To Err Is Human: Building a Safer Health System highlighted that more than 98,000 patients die each year in United States hospitals because of human error.1 Although this statistic is alarming, it is also important to highlight the fact that adverse events also lead to poor outcomes. Those poor outcomes correlate to longer recovery and hospital stays. A medical error can arise from various causes such as an error in execution (the action was not completed as planned) or an error in planning (the wrong plan was used). In addition, many errors can be termed as near misses in that no harm occurred, but there is a factor that needs to be considered. When an error does result in an injury, then it is termed an adverse event. The Institute of Medicine’s report placed an emphasis on understanding how adverse events and near misses occur in the hospital setting and having a better appreciation for what adverse events can be avoided.1 Their emphasis is on learning more about what is termed human factors.
events within the hospital was done more on an individual, risk management basis, and often lacked a clear understanding of the complexity surrounding the adverse event.3 Root cause analyses were used to identify causes of errors with sentinel events; however, these reports focused on a specific event and often overlooked the deeper system issues that required change.2 The focus now must shift to a culture of safety that embraces an open flow of information and the ability to learn about vulnerabilities within the system. It is important to note that errors are based on unintentional actions, not planned actions. With retraining, the focus is on planned behavior, overlooking the unintentional actions leading to the error. The reality is that in any systems involving human interaction, human factors are present. The challenge is bringing those specific factors to the surface because most errors are multifactorial. Highlighting patterns that can lead to injury requires a better appreciation of how humans interact in routine and challenging situations.
Human factors have been studied more frequently in areas outside health care, eg, aviation, military, and nuclear power plants. In his book, Managing the Risks of Organization Accidents and Human Errors, Reason2 notes that the analysis of human factors is the study of the interaction of equipment and individuals and the variables that can affect the outcome. Humans work within systems that may be flawed, and these flaws contribute to error. Complexity and interdependencies within organizational structure are acknowledged, and it is through the better understanding of these factors that errors can be diminished.
When examining errors, Reason2 and Drew et al3 stated that there are two elements that contribute to human errors: latent and active factors. Active factors are more common and are the actions or inactions of individuals. Active factors appear to lead to the error happening, and are typically unique to the situation, having immediate effects. Active factors can include2,3:
Health care, for the most part, was slow to respond to how human factors influenced errors. The old focus was reactive and focused on placing blame. Dealing with adverse Jacqueline Ross, MSN, RN, CPAN, is the ASPAN Director for Research, and is a Perianesthesia Nurse Consultant and Patient Safety Analyst with TDC, Columbus, OH. Address correspondence to Jacqueline Ross; e-mail address: [email protected]. Ó 2009 published by Elsevier Inc. on behalf of American Society of PeriAnesthesia Nurses. 1089-9472/09/2401-0008$36.00/0 doi:10.1016/j.jopan.2008.11.003 Journal of PeriAnesthesia Nursing, Vol 24, No 1 (February), 2009: pp 55-56
A lapse, such as not using a checklist, which leads to forgetting an important step in a process or an overreliance on memory. A slip, which refers to doing the correct action, but doing it incorrectly. Slips involve performance issues. Mistakes, which are the result of incorrect understanding of the situation, such as a wrong-site procedure. Mistakes involve decision-making; individuals choose the wrong action. Not following procedures, such as poor hand washing or verifying a patient’s name before giving a medication. Active factors are the easiest to identify because they tend to be the final product of a series of events culminating in the error. 55
JACQUELINE ROSS
56
The latent factors are harder to detect and are more related to overall organizational policy or those arising from outside the organization such as regulatory issues. Latent factors are present in all organizations and are reflected through poor communication, policies, heavy workload, poor management skills, and overall organizational culture.2,3 Examples of latent factors that have received a lot of attention are medications that are packaged similarly and medications that sound alike. Often, latent factors are not evident until an active failure occurs that leads to an adverse event, and one latent factor can lead to multiple active factors and injuries.2 Reason and Drew et al’s model of error2,3 postulates that latent factors such as organizational process and management practices lead to error-producing conditions. Latent factors can be viewed as the contributory factors involved in the error. These latent conditions could lead to active failures such as mistakes, violations of policies, and lapses. All systems contain built-in defenses, but if for some reasons these defenses fail, then an adverse event occurs. Therefore, it is essential to have a better understanding of the latent factors.2,3 A focus on examining devices is important because the United States Food and Drug Administration’s Center for Devices and Radiological Health estimated that about one third of the incident reports received annually are related to an inattention to human factors when designing the device.4 Medical devices are often complex, are used under stressful conditions, and individuals who use the device may think differently than the designers of the device.4 In fact, human factors were considered in the design of anesthesia machines so that canisters of inhaled anesthetics cannot be switched with the oxygen canisters.
Unfortunately little research has been done in the perianesthesia areas on human factors. Some research in the intensive care unit (ICU) settings has been conducted on devices and human factors. One study3 focused on therapeutic and monitoring devices in the ICU. When examining the subjective assessments of ICU nurses, the nurses identified the most important error-producing conditions as low signal-to-noise ratio, unreliable instrumentation, operator–designer mismatch, and shortage of time. Drew and others3 also inquired about how frequently errors occurred in the ICU, and the results indicated that errors were frequent, with a mean of 6.35 (9point scale, with 9 indicating higher amount of errors perceived). These device issues may lead to nurses questioning the accuracy of monitoring readouts. Are there similar concerns in the perianesthesia areas? Unfortunately, many human factors remain unknown, especially in the perianesthesia areas. It is only through ongoing reporting of near misses and adverse events that the complexity of latent factors can be highlighted and adverse events eliminated. Many institutions have instituted mandatory and/or voluntary medication error reporting systems, but it remains unclear if these systems are being used by all health care providers. The reporting systems should also expand to include more than medication safety. The culture of blame may be more difficult to change. Every member of the organization can play a part in changing this culture of blame. Investigate what systems may be in place within your organization. Encourage your leadership to begin a better assessment of those latent factors that may be lurking. One initial step may involve assessing the attitudes of the health care team to reporting near misses and errors. Education may be required. Moving to a culture of safety is essential in decreasing the incidence of adverse events.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. Reason J. Managing the Risks of Organization Accidents and Human Errors. Hampshire, England: Ashgate Publishing Limited; 1997. 3. Drew F, Muster A, Samore M. Advances in Patient Safety: New Directions and Alternative Approaches, vol. 1-4. AHRQ Publication,
Nos. 08-0034 (1-4). Rockville, MD: Agency for Healthcare Research and Quality; 2008. Available at: http://www.ahrq.gov/qual/advances2/ Accessed November 24, 2008. 4. Kaye R, Crowley J. Medical Device Use-Safety: Incorporating Human Factors Engineering into Risk Management. Washington, DC: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health; 2000.