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Archive for the ‘Human Factors’ Category

Lessons from a Cat

In culture, Human Factors, Just Culture on June 7, 2015 at 3:52 pm

Good kitty or bad kitty?

After three years of amazing litter box use (she even went in the litter box to cough up hairballs), my cat Muffin looked me in the eye and pooped right on a rug outside of her litter box. At first I thought she was sick. But then she played and acted normal for the rest of the evening. When I woke up in the morning, I noticed she had peed all over the rug. This was such unusual behavior.

I searched the internet and found many theories of cat behavior. Maybe she didnt like the new litter, maybe her box was too dirty, maybe she was upset. I decided to buy her a totally new litter box and went back to her fav kitty litter. I bought a slightly smaller box than she was used to because the other one had to squeeze into the fake furniture housing that encased it and I didn’t clean it as thoroughly as I should because it was challenging to get in and out.

It seemed to work! Muffin was doing her business back in the box. After a week or so when I took the box out to clean it, I noticed urine all underneath it. UGH! she was peeing outside the box. Maybe this was behavioral after-all. Time to google cat therapists.

Let’s look at this from a just culture lens.

Initially I thought Muffin’s defiant voiding outside of her box was a protest…malicious behavior. Then after searching cat behavior, i thought maybe she was just being reckless. Then one day after cleaning all the urine under the litter box, i noticed that the side of the pan where she usually pees was pretty short. I flipped the pan around and put the taller side in that spot. Like magic problem solved! Muffin never meant to be malicious or reckless nor was she making a mistake! With a little redesign of her environment…problem solved! She just needed new better designed equipment.

Do we support help our healthcare workers in redesigning their environment for safety or do we just accuse them of making errors and being reckless?

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Chorhexidine injected into leg 2013

In Human Factors on March 29, 2015 at 5:47 pm

The Human Factor: Learning from Gina’s Story’ which has been shown to NHS staff and organisations to show how lessons can be learned from local investigations.
A powerful video. Anyone in healthcare will cringe as soon as you see the team proceed to fill open bowls with unlabeled fluids.

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Reduce obesity and improve Patient Safety?

In Behavior change, design, Force function, High Reliability Orgs, Human Factors on March 15, 2015 at 2:01 pm

I have read much material lately about addressing the obesity epidemic and there are many commonalities in the latest theories.
1. Motivation- focusing on motivation as a strategy is not the best approach. Willpower has been dismissed by many as a poor approach to weight management
2. Behavior change- changing behaviors is not easy. Much of a person’s day consists of habitual activities resulting from cues from tv, peers, childhood… example wanting to eat popcorn while watching a movie, reaching for the salt before tasting food…
3. Environment changes-For obesity this holds the most promise. Its seen in weight watchers programs and Wansink’s book Slimdown by design. Change architecture and nudging can help make behavior change easier and lasting. This includes things like using smaller colorfull plates, moving healthy foods to a prominent kitchen spot and unhealthy foods to hidden cabinets. In some estimates people who follow certain environmental patterns are 18% thinner than those who do not.

What’s the correlation with patient safety?
1. Motivation- focusing on motivation as a strategy is not the best approach. Motivating staff to be more vigilant? Teaching them? Telling them to Follow rules and policies? These have not been shown to increase safety measurably. In fact sometimes recognizing when to deviate from rules can add resilience
2. Behavior change- changing behaviors is not easy. Other articles on this cite describe many nursing behaviors as being based on tradition and automatic behavior. Often under stress people revert back to old knowledge. How many times has an initiative been rolled out only to see it vanished from practice within a year?
3. Environment changes- just as in obesity management here we might find the most bang for our buck so to speak. Make it easy for staff to do the right thing. Make it hard for staff to do the wrong thing. Create systems that nudge staff toward safe behaviors. Use change architecture to produce reliability

A healthier world depends on reducing obesity and unsafe patient care. Maybe the solutions to both are the same.

See Reference Page for some articles related to this page

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When sorry isnt the hardest word

In adverse events, human error, Human Factors, Interuptions, Multitasking on December 14, 2014 at 8:49 am

On Monday afternoon, a tragic medication error occurred at St. Charles Bend that ultimately caused the death Wednesday of a 65-year-old patient. The St. Charles family is devastated by this situation and our thoughts and prayers go out to the patient’s family along with the caregivers who were directly involved in this case during this incredibly difficult time.

“As soon as the error was recognized, we met with the patient’s family to explain what had happened and apologized for the grave mistake. We are in the process of investigating the cause of the error and are working closely with our internal team to ensure that it will not happen again. We will be reporting the event to The Joint Commission and the Oregon Patient Safety Commission in the coming days. St. Charles has never experienced a medication error of this kind in its history.

On the surface St Charles did everything right by the family in this tragic medication error. They owned the mistake, did not blame it on individual practitioners and they apologized to the family. They go on to decribe the process by which a paralytic was dispensed instead of a seizure medication. they performed a root cause analysis and came out with an action plan. They appear committed to this action plan on every level of their organization and they seem sincere in their determination to prevent this from ever happening to another patient.

“Since Ms. Macpherson’s death, we have taken several immediate steps to ensure that an error of this kind will not happen again in our facilities.
Issue 1: Incorrect drug chosen and placed into IV
Our Response: We are enforcing a “safety zone” where pharmacists and techs are working that is intended to eliminate distractions. Verification of medication can only be completed in these areas.
Issue 2: Verification of drug dispensed
Our Response: A detailed checking process has been standardized and implemented to bring heightened awareness to the pharmacy team. New alert stickers have been added to paralytic medications and we are training nursing staff to watch for these stickers.
Issue 3: Monitoring of patient after IV started
Our Response: Nursing leaders are currently evaluating patient care processes to ensure we are following best practices. On every unit, our nurses are being hyper-vigilant about how we administer any intravenous medications. We are conducting frequent check-ins with our patients and we are consulting with patient safety experts across the country to ensure we are adhering to best practices.

The words that scare me in their action plan are those like “safety zone” “heightened awareness” and “hyper-vigilant.”
While these are admirable and many errors are caught by caregivers because of these very things, this is like medicating for an illness to cover the symptoms instead of giving a patient the cure.
Instead of a safety zone, move the dangerous drugs to another area that can only be accessed and prepared into a bag of IVF with the assistance of barcode scanning.
Instead of heightened awareness and stickers, manufacturers should make special syringes and tubing for high risk medications so they cannot be given inadvertantly.
Instead of hyper vigilance, establish staffing patterns that ensure nurses can focus on one patient at a time instead of continually multitasking. Study “priority setting” and how leaders can support front line staff by spelling out how to manage busy shifts (eg. what are essential practices for safety and what are second tier priorities like patient experience. High profile initiatives can come across as if they are more important than safety).
Proactively observe the medication process and visit nursing units to get staff’s ideas on what might be the next be error. Your staff know.
The heightened awareness and hyper-vigilance are totally people based interventions. If another medication error is made, I fear the staff will be blamed for their failure to maintain these super-human standards.

Visit http://www.sorryworks.net/oregon-hospital-apologizes-for-fatal-medical-error-shares-details-cms-272 for more info about the apology

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Neuroscience Saturdays: Stress could be a threat to patient safety

In Human Factors, Neuroscience on August 23, 2014 at 3:43 pm

It is thought that the safest hospitals are the ones with the happiest employees. What is it that makes this so… Pride? engagement?
One thing that we know doesn’t facilitate safety is stress: stress can interfere with cognitive processing..
Watch this cool presentation from the authors of BRAIN RULES a great book if you have not read it

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WE could use these labels in healthcare

In High Reliability Orgs, Human Factors, Neuroscience on May 4, 2014 at 5:04 pm

If only medical supplies had labels like this instead of the crazy font, placement and design of current hospital supply products. There is no standard place for expiration date or contents..no wonder regulators often find expired items throughout a hospital.

Go check out SAFECHART

http://cargocollective.com/petewinslow/SafeChart

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Wrong side wrong system?

In BEST.ARTICLE.EVER., Checklists, Force function, Human Factors on May 9, 2013 at 7:28 am

Another article about a recent wrong side surgery: http://www.stltoday.com/business/local/ssm-health-care-apologizes-for-brain-surgery-error/article_05e1c0fa-fd7c-5aa0-a30f-1784edfd7d39.html

“SSM Health Care acknowledged Tuesday that its neurosurgeon and medical staff recently operated on the wrong side of a St. Louis-area woman’s brain and skull.
The admission — and a lengthy public apology — followed a Post-Dispatch story in Tuesday’s paper about a lawsuit filed Friday on behalf of Regina Turner of St. Ann.
“SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room,” Chris Howard, president and chief executive of SSM Health Care-St. Louis, said in a written statement. As a result of the mistaken surgery on April 4, Turner, 53, now needs 24-hour nursing care for her basic needs and cannot speak intelligibly, said Alvin Wolff Jr., her Clayton-based attorney.
According to the lawsuit filed in circuit court in Clayton, the former paralegal “will also continue to suffer from emotional distress, anxiety, disfigurement and depression.”
“This was a breakdown in our procedures, and it absolutely should not have happened,” Howard wrote in his statement. “We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion. We immediately began an investigation.”

Time outs and checklists have reduced the incident of wrong side surgery but not eliminated the problem. Let’s analyze this from the human factors/risk management Hierarchy of Intervention Effectiveness (see graphic below).
While checklists and standard time-outs are better than education, they do not reach the level of automation or force function.

In the words of Cafazzo & St-Cyr (2012,http://www.longwoods.com/content/22845)
“Although checklist use has recently made headlines in its ability to reduce adverse events in settings such as the operating room and intensive care (Haynes et al. 2009; Pronovost 2006), it remains unclear that an intervention so fundamentally reliant on human behaviour will be sustainable in the long term without constant enforcement (Bosk et al. 2009). Are all healthcare organizations able to create a culture for the sustained use of checklists? If this solution applies only to organizations that have the leadership and resources to maintain such a culture, checklists – and other solutions reliant on human behaviour – cannot be considered a systemic solution. Given how rare serious adverse events are to the total volume of healthcare encounters, a solution that applies to only a fraction of organizations cannot address this safety issue fully.”

My thoughts: why can’t we ace wrap the WRONG side…with a distinctive sterile wrap designed like yellow police tape (DO NOT CROSS!).. it can be removed once the first cut is made into the appropriate surgical site.
Simple, but it would provide some force function as the team would literally have to remove a wrapping that said “WRONG SIDE” in order to make a mistake!
Graphic: Cafazzo and St-Cyr, 2012
http://www.longwoods.com/content/22845
A safetydog: BEST.ARTICLE.EVER.

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Do as I say not as I do

In Behavior change, Human Factors on February 3, 2013 at 12:01 pm

As healthcare workers, we are not always role-models for health. In a canadian survey 66% of healthcare workers were overweight and 18% smoked.

Do we eat breakfast? Many healthcare workers who have children know that having breakfast before school improves performance.

Boschloo, et al. (2012) studied kids age 11-18. In their results, they found that habitual breakfast skippers performed more poorly in school than habitual breakfast eaters. Performance was measured by school grades and an attention scale. This effect was true for kids regardless of chronotype (day person or night owl).

Other studies have shown lack of breakfast can affect memory (particulary verbal in girls), mood and attention.

This research comes from the relatively new field of Mind Brain Health and Education which attempts to cohort the best research from psychology, neuroscience and education to facilitate the teaching and learning of our children, with the goal of every child reaching their full potential. Perhaps patient safety might benefit if we use some of this research to help healthcare workers reach their full potentials?

Let’s start by making breakfast a habit for all healthcare workers!

(in a future post I will present some research on food types and Mind Brain Heath and Education)

Boshloo, A. et al., (2012). The relation between breakfast skipping and school performance in adolescence. Mind, Brain, and Education, 6(2), 81-88

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Find the mistake

In adverse events, human error, Human Factors, Root cause analysis on February 2, 2013 at 5:56 pm

This mini human factors test is going around Facebook.
Once you find the mistake it becomes almost impossible not to see it.

This illustrates two concepts
1) we see what we expect to see and our brain “corrects” what does not conform and therefore we can easily misread labels
2) Only hindsght is 20/20. When investigating an error after the fact, hindsight bias may cause one to think the error was foolish and was easy to detect at the time. Now that you see the error in this little picture it seems to be so evident that you wonder how it could have been missed initially

This is why we need barcode medication identification systems for preparation and administration.
And this is why it is so important to understand what was actually known at the time of an error and not what we know in hindsight. Many errors occur when people are doing what they always have done. Usually there is no significiant deviation from norm.