The Journal of Experimental Psychology: Applied just released a special issue on “Cognitive Factors in Healthcare.”
In the introductory article Morrow and Durso (2011) report that while progress has been made in the human factors front related to patient safety, problems are likely to increase in the future due to: the aging of society, The Affordable care act which will put more patients into the system, and the adoption of technology that can assist safety but often increases the complexity of providing care especially when it is not consistent with clinician needs, goals and practices. One of the challenges to research in the healthcare safety arena is the inability to manipulate variables when there can be such real consequences (Morrow & Durso, 2011). Theories applicable to aviation which is more structured and engineered don’t always translate well into healthcare which is considered to be more of a socio-natural system (Morrow & Durso, 2011). My full review continues here…
Archive for the ‘High Reliability Orgs’ Category
Articles Nurses may Never read…
In High Reliability Orgs, Human Factors, Interuptions, Patient Safety on September 25, 2011 at 4:39 pmSleep, Shower or Slip up
In High Reliability Orgs, human error on June 2, 2011 at 10:09 amSad news coming out of Japan: workers at the nuclear power plants are stressed, sleep deprived and showerless (Hongo, 2011). In addition to having lost their own homes to the Tsunami, the workers at the nuclear plants have gone up to 10 days with rest or showers in trying to keep the stricken reactors cool. The nuclear industry is already a high risk industry and these workers are really being expected to perform in a superhuman manner; dealing with occupational catastrophe as well as personal tragedy. While most of the articles are being written about the nuclear risk, there is worker risk at a much higher dimension than usual. This is truly a tragic situation.
Beyond Reason…to Resiliency
In High Reliability Orgs, human error, Human Factors, Normal Accident Theory on November 13, 2010 at 5:06 pmAn earlier post presented James Reason’s Swiss cheese model of failure in complex organizations. This model and the concept of latent failures are linear models of failure in that the failure is the result of one breakdown then another then another which all combined contribute to a failure by someone or something at the sharp end of a process.
More recent theories expand on this linear model and describe complex systems as interactive in that complex interactions, processes and relationships all interact in a non-linear fashion to produce failure. Examples of these are Normal Accident theory (NAT) and the theory of High Reliability Organizations (HRO). NAT holds that once a system becomes complex enough accidents are inevitable. There will come a point when humans lose control of a situation and failure results; such as in the case of Three Mile Island. In High Reliability Theory, organizations attempt to prevent the inevitable accident by monitoring the environment (St Pierre, et al., 2008). HRO look at their near misses to find holes in their systems; they look for complex causes of error, reduce variability and increase redundancy in the hopes of preventing failures (Woods, et al., 2010). While these efforts are worthwhile, this still has not reduced failures in organizations to an acceptable level. Sometimes double checks fail and standardization and policies increase complexity.
One of the new ways of thinking about safety is known as Resilience Engineering. … Read the rest of this entry »
Dead by Mistake
In High Reliability Orgs, hospital, Patient Safety, safety, Safety climate on October 29, 2010 at 8:03 pmHealthcare providers know that the public is invested in the reporting of and the prevention of medical errors. The website Dead by Mistake is run by Hearst newspapers and is a consumer oriented site with scary stories of medical mishaps that would make even the bravest among us afraid to receive hospital care.
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BP blames rig explosion on series of failures
In High Reliability Orgs, Patient Safety on September 8, 2010 at 12:42 pmMore 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 Today.com
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