Integrating Human Factors Into Incident Investigation

8/12/2019 Integrating Human Factors Into Incident Investigation

1/29

Integrating human factorsinto incident investigation

Dr Jane Carthey, Human Factors Specialist


2/29

Overview of the workshop

1. Discuss what a human factors-based approachto incident investigation looks like.

2. Explore the current challenges faced byhealthcare teams when carrying out incidentinvestigations

3. Forum for sharing ideas for integrating humanfactors into incident investigation


3/29

Getting started Look at the photograph Discuss what you see with the person next

to you


4/29


5/29

Quick task Reflect on your comments and decide which ones

are Facts and which are Assumptions


6/29

Current approaches &Challenges


7/29

The London Protocol

www.cpssq.org


8/29


9/29

Not about whodunnit


10/29

Challenges


11/29

Cognitive biases: hindsight and outcome bias


12/29

Witness memory degradation


13/29

Paradigms

Place (theclinical area,equipmentinvolved).

Paper (i.e. documentation)(medical records, shiftrotas, incident report,complaint letter etc..)

People (i.e. those who were involved andalso who witnessed what happened)- Use interviews, witness statements

Most obscure!Tapping into

the way we do thingsaround here


14/29

Timelines mapping can go too far!!


15/29

The sorry lot of the healthcareincident investigator

Two days training in incident investigation methodology Demand means that you go straight from theory into practice. Learning on the job. Training does not prepare you for the emotional aspects. Investigation carried out alongside the day job Infra-structure within a Trust to peer review, mentor and support. Investigators have to be clinical ly trained - Human factors expertise not included as standard


16/29

Focus on the active errors, not the systemfailures

Intrathecal vincristine administration Active error: two junior doctors checking error Often identified as the root cause But making a recommendation to improve checking or to add

in additional checks leaves other important latent failures inthe system Therefore there is a real risk that the incident will happen

again


17/29

STRONGACTIONS

Physical plant or equipment re-designNew device with usability testing before purchasingEngineering controls (interlock / forcing function)Simplify the process and remove unnecessary stepsStandardise equipment or processes or care plansTangible involvement and action by leadership in support ofPatient Safety

MODERATELYSTRONG

Increase in staffing / decrease in workload

Software enhancements / modificationsEliminate / reduce distractionsChecklist / cognitive aidEliminate look and sound-a-likesEnhanced communication

WEAKACTIONS

Double checks

Warnings and labelsNew procedure / policyTrainingDisciplinary action

Solutions and recommendations

Lee and Hirschler


18/29

Intuitive design Make it possible to only

carry out a task one way the safe way!

Think intuitive! Design to do safely


19/29

Content atrainability 2010 & JC Consulting

PERFORMANCE

V E R Y

U N S A F E S P A C E

BeliefSystems .

Life Pressures

The posted

speed limit is70 mph- thelegal space

INDIVIDUAL BENEFITS

Driving 75mph- theIllegal-normalspace

Driving95+ mph the illegal -

illegalspace (foralmost all

of us!)

Perceived vulnerability

ACCIDENT

Systemic Migration to Boundaries (Amalberti, 2008)


20/29

Factors that increase non-compliancePerceived low likelihood of detection Lack of awareness/understanding of policies and procedures

Misperception or lack of recognition of risk Self-perceived authority to violate Time pressure/pressure to get the job done Copying behaviour (i.e. learn to do the procedure from a colleague who is non-compliant)

Lack of leadership Lack of end-user engagement when policies and procedures are written.

Policy and procedure overload (for example, confusion over which procedure applieswhen) Ambiguous or conflicting messages in the policy/procedure Lack of training and reinforcement of key policy messages over time. No sanctions imposed for non-compliance Lack of monitoring systems to check procedural compliance Policies and procedures are inaccessible Out of date procedures/policies Mismatch between the policy/procedure and how the job is actually done.


21/29

Considering human factors in design:Infection control tannoys

Great idea butno timer Keep patients awake at night So ward staff switch them off

because the design of thetannoy enables thisworkaround.

Capacity for 2 messages Infection control and. Please help us to reduce our

carbon footprint, recycle yourwaste


22/29


23/29

WSS tendon repair incidenti. Operation requires use of splint which obscured the finger

involvedii. Prep fluid removed initial markingiii. WHO Surgical Safety Checklist carried out before prepping and

draping

ONLY NUMBER 3 IDENTIFIED AS A ROOT CAUSE FOCUS ON THE PROXIMAL CAUSE

INVESTIGATOR FOCUS ON POOR DOCUMENTATION OF WHATHAPPENED IN THE CLINICAL NOTES AS A CONTRIBUTORY FACTOR

Yorkshire Contrib tor Factors Frame ork


24/29

Yorkshire Contributory Factors Framework

Lawton et al., 2011. BMJ Qual Saf doi:10.1136/bmjqs-2011-000443


25/29

Never! (CHFG, 2012)Equipment Poor planning meant imaging equipment needed in more than one place at the

same time Skin marking pens not always available; procurement and stock management

failures Theatre table design that means turning it round loses visual cues

Information, data and records Delays in patient records being filed Multiple, pre-printed name labels meant any mistakes were perpetuated Not all information available at MDT meetings Abbreviations leading to errors RT and groin misinterpreted Jobs/tasks/protocols Surgeons operating without having had time to see patients or read their notes Management meetings or meetings on other sites conflicting with theatre times Environment Working in theatres with different layouts display boards not visible, table and

equipment laid out the opposite way round

Work carried out by Susan Burnett, Joan Russell, Beverly Norris and Rhona Flin


26/29

Never ! (CHFG, 2012)Work design The WHO Checklist seen as an added, unnecessary task rather than an integral part of process

Staff breaks and interruptions were not planned forCulture and organisation Acceptance of time pressures causing shortcuts and failures to follow procedure Hierarchies preventing staff speaking up or asking for help Poor safety culture meant the checklist was seen as a burden rather than a tool for staff to protect

themselves against errorsCommunication Between frontline staff and management: Poor consultation on new ways of workingStaff patient communication: Issues with obtaining consent/patient involvement Poor access to translator servicesCommunication between teams and different staff groups: Failures to speak up when checklist not followed Lack of a double checking protocol when side for procedure is not obvious, e.g. when viewing on screenOrganisation Unrealistic expectations of staff to cope with time pressures and workload

Work carried out by Susan Burnett, Joan Russell, Beverly Norris and Rhona Flin


27/29

What does a good HF approach look like?

How might we ensure that humanfactors is better integrated intoincident investigations in healthcare?


28/29

Just a Routine Operation


29/29

Reasons Swiss cheese model

Patient SafetyIncident

LATENTCONDITIONS: poordesign,procedures,managementdecisionsetc..

ACTIVE ERRORS

Levels of defence

Documents

Integrating Human Factors Into Incident Investigation