Archive for September, 2010|Monthly archive page

User Interfaces and Safety

In Human Factors on September 25, 2010 at 4:38 pm

I upgraded to a new android touch screen phone this week, the Motorola Backflip. What a great little device! It’s so easy to use and so much faster and lighter than my old Windows Mobile phone. The user interface was so intuitive, I barely had to open the instruction booklet.
I am having only one problem and it’s a major one…more Read the rest of this entry »

Brainwrite, not storm!

In Patient Safety, Root cause analysis, Teamwork on September 24, 2010 at 7:43 pm

When a safety issue arises hospitals often convene a team to come with ideas for a safer process. Three types of teams include project teams, virtual teams, and quality circles. A project team is time limited and focused on a one-time output (Borkowski, 2011). They are usually formed to solve a particular problem and exist only until that problem is resolved (Landy & Conte, 2010). A virtual team needs technology to exist. These teams can be permanent or task focused and are defined by their ability to work across time, space and physical distance (Borkowski, 2011). Quality circles are like mini think tanks where a group of employees convenes to identify problems and generate ideas (Landy & Conte, 2010). This group submits these suggestions to management who then decide whether to act on these proposals (Landy & Conte, 2010)…moreRead the rest of this entry »

Stressors, Strains and Moderators

In I-O Psychology on September 21, 2010 at 9:46 pm

Since staff stress is often mentioned in regard to safety issues in healthcare I thought I would post an overview of some theories of stress.

General Adaptation Syndrome
Seyle identified what is known as the stress response (Landy & Conte, 2010). This response follows the same process in humans whether the source of the stressor is physiological or psychological. This process is known as General Adaptation Syndrome (GAS) and has three stages (Landy & Conte, 2010). In the alarm reaction stage the body prepares to deal with the stressor by releasing hormones that control processes such as heart rate. In the resistance stage the body focuses on the original stressor and copes with that, however responses to any other stressors are lowered (Landy & Conte, 2010). The final stage is exhaustion and in this stage the body decreases all responses to stress (including the original source) and becomes susceptible to psychological and physiological diseases/syndromes (Landy & Conte, 2010). One of the consequences of this stage in terms of the workplace can be the development of burnout. Burnout is an extreme state of psychological Read the rest of this entry »

A bit of I-O Psychology History

In I-O Psychology on September 21, 2010 at 9:38 pm

In Psychology, all roads lead to Ancient Greece. The discipline of Industrial-Organizational (I-O) Psychology can trace its roots to Plato’s The Republic when he classifies citizens into guardians, auxiliaries and workers and gives selection and training advice (Katzell & Austin, 1992). In the book of Exodus, Moses sought advice on how to organize the ancient Israelis (Katzell & Austin, 1992). The study and employment of I-O Psychology principles similar to those used today however, really began in the early 1900s (Katzell & Austin, 1992).
Hugo Munsterberg, a professor at Harvard, Read the rest of this entry »

Scratch Tickets & Independent Double Checks

In Human Factors, Interuptions, Multitasking, Normal Accident Theory, Patient Safety, Teamwork on September 19, 2010 at 2:34 pm

I played tennis this morning with a friend. On the way home I thought I would stop at the supermarket to pick up some snacks for the Patriots game today. I realized I forgot my debit card (ah, the limitations of the human memory). Looking for alternate forms of payment, I found winning lottery scratch tickets in my glove compartment.

I quickly added them up (3 of them) and confirmed that … Read the rest of this entry »

The “smart room” by GE

In Human Factors, Patient Safety, Safety climate on September 16, 2010 at 7:46 pm

The future of safety?

click here

Missed Care: an error of omission

In Interuptions, Multitasking, Patient Safety on September 16, 2010 at 7:21 pm

According to Kalisch, Landstrom and Hinshaw (2009) one overlooked aspect in addressing patient safety is the concept of “missed care.” Missed care is classified in terms of error as an act of omission. Missed care is a concept that nurses are very well aware of but hesitant to bring into open discussion (Kalisch,, 2009). Some reasons suspected for covering up these omissions are guilt, a feeling of powerlessness to correct the situation and fear of punishment for not completing tasks. There are even reports of false documentation to hide these errors of omission because of fear of retribution and an acceptance of this being the norm (Kalisch, et al, 2009). Kalisch, et al, (2009) liken this hiding of these errors to the hiding of medication errors and near misses that was prevalent prior to the patient safety movement…. more Read the rest of this entry »


In I-O Psychology on September 13, 2010 at 7:30 pm

The link to this amazing resource is pinned at the bottom of this site. If you haven’t had a chance to check it out maybe the impressive list of journals from which they select their comentaries will entice you!
Click for larger view

Fun with Human Factors Part Two

In Patient Safety on September 11, 2010 at 5:26 pm

Try this training exercise from the IHI Open School for Health Professionals:

Visit any of the following: •Restaurant •Coffee shop •Transportation system •Retail store •Hotel •Major intersection •Library •Health care setting

Take note – can you spot human factors issues that create opportunities for errors?
•What processes rely on memory?
•What tools can be used to eliminate the need to rely on memory?
•How well would the processes you observe work if the individual involved were tired? Distracted?
•What types of errors might occur? How would someone know if these error(s) had occurred?
•Are there steps that can be skipped or bypassed? Is this a good or bad design? Why?
•Would a new person be likely to make more, less or the same number of errors as an experienced person? Why?
•Are there systems in place ‐‐ or that should be in place – to minimize the opportunities for error?

If you have a chance to perform this exercise please share your observations in the comment section 🙂

BP blames rig explosion on series of failures

In High Reliability Orgs, Patient Safety on September 8, 2010 at 12:42 pm

More support for the swiss cheese theory of accident causation and normal accident theory:

“It is evident that a series of complex events, rather than a single mistake or failure, led to the tragedy,” said Tony Hayward, BP’s departing chief executive.

Read the story on USA

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