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*TS: Human Factors Analysis in Patient Safety Systems (PDF/QV) [REF: AOM, LDR, PI] The Source, April 2015, Vol 13, #4, Pg 1 JCs1504_B3
According to statistics reported in this month’s Perspectives, ‘Human Factors’ are the #1, most frequently identified root cause of Sentinel Events reported to the Joint Commission (see Article 1504B2). This article makes it clear that an RCA or FMEA must include human factors analysis to be considered thorough. It also encourages analysis of such factors when there are incidents or close calls related to the Patient Safety System. Both are considered failures that should be analyzed. Two types of failures are distinguished in a sidebar on page 7.
1 – Active Failures… defined as “unsafe acts committed by front line staff” and are further classified as Errors (honest mistakes) and Violations (deliberate disregard of safety regulations).
2 – Latent Failures… considered “underlying weaknesses in systems or processes”. These can be categorized by organizational factors, supervisory issues and unsafe preconditions.
The article also makes the point that some responses to human factor-related failures (which it calls Human Factors Engineering Strategies) may be more sustainable and reliable (Hint: think High Reliability). It is noteworthy that the most common strategies used to address active failures (i.e., education, training and policy changes) are also among the least reliable and do not address underlying (latent) system issues. Examples of more reliable approaches are listed in Table 1 on page 10.
Tip 1: Think of Human Factor Analysis as another tool for helping to achieve high reliability and a Just Culture. LDR should consider obtaining more background on James Reason’s article, Human error: Models and management. BMJ. 2000 Mar 18;320 which is the principle basis of this TJC article.
Tip 2: PI, LDR and those responsible for monitoring and evaluating patient safety, should assess for human factors more rigorously in incidents and close calls related to patient safety, and be more intentional in using more reliable human factor engineering strategies in response.
Tip 3: Conduct a tracer/FMEA of the new Patient Safety Systems Chapter; analyze findings of non-compliance for human factors and then use higher reliability strategies to proactively respond. Note: This can also be used as a good illustration of your ability to perform intensive analysis for survey purposes.
See Also: Comments section for additional info and references.
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One response to “RTN1504_B3_Human Factor Analysis”
TJC Abstract:
Human factors analysis (also referred to human factors engineering) is an essential step to designing equipment, procedures, tasks, and work environments because research shows that human failures cause 80% to 90% of errors. Human factors is a human-centered science using tools and methods to enhance the understanding around human behavior, cognition, and physical capabilities and limitations, and applying this knowledge to designing systems in support of these capabilities and limitations. In health care, close calls or incidents manifest when processes do not match or support the known human cognitive and physical limitations and capabilities. This article discusses the analysis of human factors related to patient safety.
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Excerpt: AHRQ Patient Safety Primer: Systems Approach (featuring James Reason)
The modern field of systems analysis was pioneered by the British psychologist James Reason, whose analysis of industrial accidents led to fundamental insights about the nature of preventable adverse events. Reason’s analysis of errors in fields as diverse as aviation and nuclear power revealed that catastrophic safety failures are almost never caused by isolated errors committed by individuals. Instead, most accidents result from multiple, smaller errors in environments with serious underlying system flaws. Reason introduced the Swiss Cheese model to describe this phenomenon. In this model, errors made by individuals result in disastrous consequences due to flawed systems—the holes in the cheese. This model not only has tremendous explanatory power, it also helps point the way toward solutions—encouraging personnel to try to identify the holes and to both shrink their size and create enough overlap so that they never line up in the future.
Another of Reason’s key insights, one that sadly remains underemphasized today, is that human error is inevitable, especially in systems as complex as health care. Simply striving for perfection—or punishing individuals who make mistakes—will not appreciably improve safety, as expecting flawless performance from human beings working in complex, high-stress environments is unrealistic. The systems approach holds that efforts to catch human errors before they occur or block them from causing harm will ultimately be more fruitful than ones that seek to somehow create flawless providers.
Reason used the terms active errors and latent errors to distinguish individual from system errors. Active errors almost always involve frontline personnel and occur at the point of contact between a human and some aspect of a larger system (e.g., a human–machine interface). By contrast, latent errors are literally accidents waiting to happen—failures of organization or design that allow the inevitable active errors to cause harm.
Read Full article: http://psnet.ahrq.gov/printviewPrimer.aspx?primerID=21
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Additional References by/about James Reason
[Note: This author is currently quite popular/frequently quoted by TJC relating to High Reliability and Just Culture
• Reason, James. Human Error. New York: Cambridge University Press, 1990.
• Reason J. Human error: Models and management. BMJ. 2000 Mar 18;320 (7237):768–770. {http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117770/}
• Reason, James. The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci. 1990 Apr 12;327(1241):475-84.
• Swiss cheese model – Wikipedia, the free encyclopedia
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