Human Factors - Boonshoft School Of Medicine

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Importance of Human Factors inQuality ImprovementJennie J. Gallimore, Ph.D.Dept. of Biomedical, Industrial,and Human Factors EngineeringWright State University1Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

ErrorYou’ve carefully thought out all the angles.You’ve done it a thousand times.It comes naturally to you.You know what you’re doing, its what you’vebeen trained to do your whole life.Nothing could possibly go wrong, right ?2Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Think Again.3Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

OutlineHuman Factors DefinedWhat Do Human Factors Engineers do?Human Error Analysis: One Example TechniqueHow should you get started?Document System ChangesConclusion4Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Factors DefinedHuman Factors discovers and applies information abouthuman behavior, abilities, limitations, and othercharacteristics to the design of tools, machines, systems,tasks, jobs, and environments for productive, safe,comfortable, and effective human use (Sanders andMcCormick, 1993)Human Factors IS NOT just applying checklists and guidelinesjust using oneself as the model for designing thingsjust common sense5Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Cost of Ignoring Human Factors IsPoor Quality!Increased probability of accidents and errorsLess spare capacity to deal with emergenciesIncreased labor turnoverLower productive outputIncreases in lost timeHigher medical costsHigher material costsIncreased absenteeismLow quality workInjuries, strains6Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs Do?Human Factors Engineering uses a systems analysisapproach.Humans are considered a critical system component.HFEs analyze systems focusing on human operators todetermine what they are required to do to achieve systemgoals.HFEs determine how the system can be designed ormodified to meet goals.Humans have certain capabilities and limitations, and thesystem must be designed with an understanding of thehuman component subsystem requirements.7Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs System DesignModifications,Performancesupport, AidsIntegrateSolutions8Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs System DesignModifications,Performancesupport, AidsIntegrateSolutionsSystem AnalysisFunction analysisG Task Analysis (cognitive, physical)G Accident/incident analysisG Workload analysisG Communication patterns/information flowG Work place layoutG Environmental AnalysisG Task-Interface analysisG Reliability assessment (Human error analysis)G Etc.G9Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs System DesignModifications,Performancesupport, AidsIntegrateSolutionsSystem AnalysisSystems Analysis Tools/TechniquesActivity samplingG Hierarchical task analysisG Link analysisG Simulation studiesG Verbal protocolsG InterviewsG QuestionnairesGCritical Incident TechniquesG Decision action treesG Decision laddersG Operator action event treesG Time line analysisG Time and motion studyG Etc.G10Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs Do?PerformScientificResearchSystem msAnalysisIntegrateSolutionsSystem ModificationsRedesign of workflow (task sequence, responsibility)G Environmental improvements (noise, lighting, alarms)G Redesign of information flowG Development of support technologyG Changes to system interfacesG Suggest changes to organizational policiesG Develop training programsG Incorporation of safety systemsG11Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs System DesignModifications,Performancesupport, AidsIntegrateSolutionsIntegration of SolutionsOrganizational changes and supportG TrainingG New TechnologyG Cost-benefit analysisG12Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

What Do HFEs System DesignModifications,Performancesupport, AidsIntegrateSolutionsHuman Factors ResearchR&D of system and task analysistechniquesG Human decision makingG Cognitive modelingG Mental workloadG Visual performanceG Shift workG Simulation and modelingG Display of informationGEffects of aging on performanceG Adaptive displaysG CommunicationG Test and EvaluationG Usability TestingG Human computer interactionG SafetyG TrainingG BiomechanicsGPhysical workloadG Manual material handlingG Human ErrorG Virtual EnvironmentsG Complex system modelingG Human control and trackingG Auditory perceptionG Multi-modal interfacesG Individual differencesG13Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Error Analysis:One Example of a Human FactorsAnalysis Technique14Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Error and Accidents “Human beings by their very naturemake mistakes; therefore, it isunreasonable to expect error-freehuman performance.” Shappell & Wiegmann, 199715Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Error and Accidents It is not surprising then, that human error hasbeen implicated in 60-80% of accidents incomplex systems. In fact, while accidents solely attributable toenvironmental and mechanical factors have beengreatly reduced over the last several years, thoseattributable to human error continue to plagueorganizations.16Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

OrganizationalFactorsWhere Do We Usually Lookto Prevent Accidents?ionsiverpSuseftionaisdUnconerPUnsafe Acts17Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Error and AccidentsWhy is the human blamed?It is human nature to blame what appears to be theactive operator when something goes wrong.Our legal system is geared toward the determination ofresponsibility, fault, and blame.It is easier for management to blame the worker than toaccept the fact that the workplace, procedure,environment, or system needs improving.The forms we fill out to investigate accidents areusually modeled after the unsafe act, unsafe conditiondichotomy.18Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Where Should We Lookto Prevent ntionsiverpSuseftionaisdUnconerPUnsafe Acts19Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Factors Analysis andClassification System (HFACS)HFACS is based on the “Swiss Cheese” model oferror by James Reason (1990)Applied to human error analysis in aviation byScott Shapell, Ph.D., Civil Aeromedical Institute andDoug Wiegmann, Ph.D., University of Illinois20Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

HFACS: Guiding PrinciplesPrinciple 1: Health care systems are similar innature to other complex productive systems.Principle 2: Human errors are inevitable withinsuch a system.Principle 3: Blaming errors on the human is likeblaming a mechanical failure on the device.Principle 4: An accident, no matter how minor, isa failure of the system.Principle 5: Accident investigation and errorprevention go hand-in-hand.21Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Breakdown of a Productive SystemInputs EconomicinflationOrganizationalFactorsLatent Conditions Excessive cost cutting Inadequate promotion policies Few qualifiedprofessionalsUnsafeSupervision RegulationsLatent Conditions Deficient training program Improper crew pairing GovernmentpoliciesPreconditionsforUnsafe ActsActive and Latent Conditions Poor team work/team resource management Loss of situational awarenessUnsafeActsFailed orAbsent DefensesActive Conditions Incorrect calculation of dosage Incorrect use of equipment Did not communicate all neededinformation Did not check deviceAdapted from Reason (1990)Accident/Injury22Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

ptionalDECISION ERRORUnsafeActs Rule-based Decisions- If X, then do Y- Highly Procedural Choice Decisions- Knowledge-based Ill-Structured Decisions- Problem solving23Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

outineExceptionalSKILL-BASEDERRORS Attention Failures- Breakdown in information scan- Inadvertent operation of control Memory Failure- Omitted item in checklist- Omitted step in procedure- Forgot to check device24Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

outineExceptionalPERCEPTUALERRORS Misread label Misread chart Misjudge type of auditoryalarm25Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

ineExceptionalROUTINE (INFRACTIONS)(Habitual departures from rules condoned by management)UnsafeActs Violation of Orders/Regulations/Standard Operating Procedures-not checking ID bands-failure to confirm allergy status when ordering antibioticin doctors office-Double check system for blood transfusion-Side bed rails not raised Failed to Adhere to policy Not Current/Qualified for procedure Improper Procedures26Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

ptionalExceptionalEXCEPTIONAL(Isolated departures from the rules not condonedby management)UnsafeActs Violated- Keep drugs on floor- Extending surgical procedure without patient consent Accepted Unnecessary Hazard Not Current/Qualified for Procedure Violated standard medical practice27Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

PRECONDITIONSFORUNSAFE sCrew sforUnsafe ActsADVERSE MENTAL STATEUnsafeActs Loss of Situational Awareness Circadian dysrhythmia Alertness (Drowsiness) Overconfidence Complacency Task Fixation28Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

PRECONDITIONSFORUNSAFE forUnsafe rsPhysical/MentalLimitationsCrew ResourceMismanagementPersonalReadinessADVERSE PHYSIOLOGICALSTATES Medical Illness Extreme fatigue29Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

PRECONDITIONSFORUNSAFE forUnsafe rsPhysical/MentalLimitationsCrew TALLIMITATIONS Lack of Sensory Input Limited Reaction Time Incompatible Physical Capabilities Incompatible Intelligence/Aptitude30Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

PRECONDITIONSFORUNSAFE sCrew sforUnsafe ActsUnsafeActsCREW RESOURCEMISMANAGEMENT Not Working as a Team Poor team Coordination Improper Briefing Before a Procedure Inadequate Coordination ofmaterials/technologies/human resources31Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

PRECONDITIONSFORUNSAFE logicalStatesPreconditionsforUnsafe eratorsOperatorsPhysical/MentalLimitationsCrew inessPERSONAL READINESSUnsafeActsReadiness Violations Rest Requirements Self-MedicatingPoor Judgement Poor Dietary Practices Overexertion While Off Duty32Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

nsFailed toCorrectProblemSupervisoryViolationsINADEQUATE SUPERVISION Failure to Administer Proper Training Lack of Professional GuidancePreconditionsforUnsafe ActsUnsafeActs33Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

nsFailed PRACTICES Risk without Benefit Improper Work Tempo Poor Team PairingPreconditionsforUnsafe ActsUnsafeActs34Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

nsFailed toCorrectProblemSupervisoryViolationsFAILED TO CORRECT AKNOWN PROBLEM Failure to Correct Inappropriate Behavior Failure to Correct a Safety HazardPreconditionsforUnsafe ActsUnsafeActs35Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

nsFailed toCorrectProblemSupervisoryViolationsSUPERVISORY VIOLATIONS Not Adhering to Rules and Regulations Willful Disregard for Authority bySupervisorsPreconditionsforUnsafe ActsUnsafeActs36Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

encesOperationalProcessRESOURCE MANAGEMENT Human Monetary rUnsafe ActsUnsafeActs37Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

RGANIZATIONALCLIMATEOrganizationalInfluences Structure Policies CultureUnsafeSupervisionPreconditionsforUnsafe ActsUnsafeActs38Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

ervision Operations Procedures OversightPreconditionsforUnsafe ActsUnsafeActs39Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

FAR Part 91 - General Aviation:Fatal vs. Non-Fatal Accident ComparisonDecision ge of AccidentsPercentage of AccidentsSkill-based 9495Year969798 * Incomplete9091908080Percentage of AccidentsPercentage of ear9596979495969798 * IncompletePercentages do not add up to 100%Violations1001093YearPerceptual Errors9092Percentages do not add up to 100%98 * IncompletePercentages do not add up to 495969798 * IncompletePercentages do not add up to 100%40Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Research SponsorsInterventionand PreventionProgramsHumanError- Errors occurfrequently and arethe major cause ofaccidents.- Few safety programsare effective atpreventing theoccurrence orconsequences ofthese errors.Fad-DrivenResearch- AHRQ, NPSF, Health systempartners, VA, NIH- Lack of adequate funding forsafety research in healthsystems.- Lack of good data leads toresearch programs basedprimarily on interests andintuitions. Interventions aretherefore less nvestigation- Lack of sophisticatedtechniques andprocedures- Information isqualitative andillusive- Focus on “what”happened but not“why” it happenedAccidentDatabase- No real accidentdatabase- Not designedaround anyparticular humanerror frameworkDatabaseAnalysis- Few analyses havebeen performedto identifyunderlyinghuman factorssafety issues.- Variables often illdefined- Organization andstructure difficultto understandFeedbackWiegmann, D. & Shappell, S. (In press). Human error analysis of commercial aviation accidents: Application of the Human FactorsAnalysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine.41Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Research SponsorsData-DrivenFad-DrivenInterventionand ndandproceduresprocedures- Errors occur lessfrequently and arefrequently.the major cause of- Safetyprograms areaccidents.effective atpreventingthe- Fewsafety programsoccurrenceare effectiveoratconsequencespreventing theoftheseerrors.oroccurrenceconsequences ofthese ��what”bothhappenedbut not“what” happened“why”it happenedand “why”- ,VA, NIHsystem partners- Researchprogramsare needsLack of adequatefundingforbasedanddata-driven.safety research in healthInterventionsare thereforesystems.very effective.- Lack of good data leads toresearch programs basedprimarily on interests andintuitions. Interventions aretherefore less effective.AccidentDatabaseDatabaseAnalysis- NotDesigneddesignedaround aaround any humanwell-knownparticularerrorframeworkhumanerror framework- Well-defined- Variablesvariables often illdefined- Organization and- Organizationstructure easyandtostructure difficultunderstandto understand-AnalysesFew analysescan nowhavebeenbeperformedperformedtoto identifyidentifyhumanunderlyingfactorssafetyhuman factorsissuessafety issues.- Traditionalhuman factorsanalyses are lessdifficult due towell-definedvariables anderror database-HFACSFeedback42Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Factors Has Been Effectively Appliedto a Variety of Complex SystemsAviationDesign of aircraftAir Traffic controlNuclear Power PlantsManufacturingAerospaceSpace stationSpace shuttlesAnesthesiologyComputer SystemsRemotely Operated VehiclesAutomobiles43Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

How Should We Start?Get a degree in human factors in your spare time!44Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

How Should We Start?Get a degree in human factors in your spare time!45Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

How Should We Start?Work with a human factors consultant specialistUse your purchasing clout to work with vendorsBe sure to document benefits from systemmodificationsIt is important to determine how analysis andintervention have affected the system. Cost-benefitanalysis is an important aspect of the systemsengineering approach.46Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Example System BenefitsReduction in reportedincidents and accidentsReduction in errorImproved communicationReduced personnelrequirements becausetasks can be more easilyaccomplishedIncreased customersatisfactionMore quality time withcustomersReduced job injuriesReduced patient waitingtimesLess “lost” information(forms, documents, etc)Better handoffReduced workloadIncreased worker jobsatisfactionEtc 47Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

ConclusionThe profession of Human Factors is dedicated toimproving the quality of complex systems.Lessons learned can be directly applied to medicalsystems. Work with Human Factors Engineers tobenefit from their expertise.48Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

AcknowledgementsThanks to Scott Shapell, Ph.D., from the CivilAeromedical Institute and Doug Wiegmann,Ph.D., from the University of Illinois forpermission to use and edit slides from theirpresentation “A Human Factors Approach toAccident Analysis and Prevention.”49Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Suggested ReadingIntroductory Textbooks on Human FactorsSanders, M.S. and McCormick, E.J. (1993) Human Factors inEngineering and Design, 7th Ed. New York: McGraw Hill, Inc.Wickens, C.D., Gordon, S. E, and Liu, Y. (1998) An Introductionto Human Factors Engineering. New York: Addison-WesleyEducational Publishers, Inc.Bogner, M. S. (Ed.) (1994). Human error in medicine.Hillsdale, NJ: Lawrence Erlbaum Associates.Reason, J. (1990). Human error. Cambridge, England:Cambridge University50Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering

Human Factors Defined Human Factors discovers and applies information about human behavior, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs, and environments for productive, safe, comfortable, and effective human use (Sanders and McCormick, 1993) Human Factors IS NOT

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