Archive for the ‘Human Factors’ Category

Transparent Health

In adverse events, culture, Human Factors on June 23, 2012 at 3:20 pm

Excellent patient safety resources from the folks at University of Illinois at Chicago.
Their blog:
There is a great post about collusion. If you see safety issues in healthcare and do not report, you should feel culpability.

Their educational site

If you are a healthcareworker, spend the $75 and Watch the Lewis Blackman story. You will be motivated to become a patient safety advocate. Lewis who was a totally healthy 15 year old, went in for elective surgery and died from a GI bleed related to toradol post op. The sequence of events happen everyday…there is nothing earthshattering until..there is.
Some key topics in this film: premature closure, confirmation bias, rapid response teams, chain of command, identification of rank of healthcare workers…listening to parents concerns..
Click to purchase pay-per-view From tears to transparency

$9.6 million fine? will that make our blood supply safe?

In Human Factors on January 18, 2012 at 8:10 am

FDA fines Red Cross nearly $9.6 million for blood safety lapses.

FDA fines Red Cross nearly $9.6 million for blood safety lapses. Is this kind of fine realistic?  Where does the money go when the FDA receives it?

Wouldn’t losing $9.6 million seem to put the ARC more at risk for safety failures?

It seems a better process would be to shut down areas that were non-compliant until they function safely.

Read the violations here:
Some thoughts from

How fast is your intuition?

In Human Factors on December 29, 2011 at 2:24 am

This is a test of your intuition. Do not try to solve this but do use your intuition to arrive at the quickest answer.

“Thinking fast and slow” a fantastic book by Pulitzer prize winner, Daniel Kahneman.  The concepts in this book have implications for how we structure work processes so that our brains function they way we need them to to prevent safety transgressions.

More Fogg….

In Behavior change, Human Factors, usability on November 7, 2011 at 7:20 am

Caroline Jones over at used BJ Fogg’s B=MAT method to describe a simple change around the office.   It is a great read and shows the Fogg behavior model in action.

“People are creatures of habit and this can introduce challenges should you want them to adopt a new behaviour. We all start forming and evolving our behaviours from the time we are born, and each of us will respond to different stimuli in our own unique way. Some of us can’t start their day without our morning coffee whereas others will reach for a cigarette as a first port of call. Some can’t fall asleep without a book in their hands and others like to leave their T.V. switched on. These behavioural differences are a big part of what makes us human….Read More

Articles Nurses may Never read…

In High Reliability Orgs, Human Factors, Interuptions, Patient Safety on September 25, 2011 at 4:39 pm

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…

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Mobile Persuation: the future of patient safety?

In Human Factors, Resiliency on September 24, 2011 at 6:56 pm

Many experts believe mobile phones are the future of societal behavior change (Fogg & Eckles, 2007). They are light and full of features and the wireless networks on which they run rival speeds of wired high speed systems. The best feature of mobile phones that contribute to persuasive behavior change is their ability to relay information, make that information actionable and maintain links to social networks. The social connection is where the real magic happens (Fogg & Eckles, 2007). From a mobile platform one could conceivably fall in love, start a revolution, read a life changing book or find a treasure.

In terms of patient safety, I see the ability to act on information as well as the social interaction to hold the most promise. Abnormal labs are sent to an MD who can click on them which takes him to an order set designed for treating the anomalies. This relays to a nurse who carries out the treatment and is beeped if any of the patients vital signs are compromised or even if the patient calls to report a symptom. A nurse could see what the patient ordered for a meal and put a hold on it if it contained too much potassium for example.
With gps and bluetooth, healthcare providers can be tracked on handwashing performance or prompted to wash when they pass a pump. A provider who cant come to a bedside could chat in real time with words and video.
Phones can already scan product barcodes and this technology could enable healthcare providers to have all patient information with them wherever they went.

It’s time to throw out those one way pagers and switch to interactive technology. Pagers function well in a hierarchical system, however if relational coordination is a safety goal, the technology has to facilitate relationships and action.


In Human Factors, Patient Safety on February 21, 2011 at 7:06 am

Paul Levy had a great post on his Not Running a Hospital blog (formerly Running a Hospital) about signage. Since this is a topic in the human factors realm, I would like to share his post and relay a story from a friend.

A couple of days ago my friend visited a local Boston community hospital known for its customer service to have a simple KUB (abdominal xray).   She was told to dress in a hospital gown (I will post more about hospital gowns in the future…is having patients all look alike adding or subtracting from safety????) and wait in a waiting area.  After almost 60 minutes, she noticed staff hanging around the desk and talking and laughing.  Drawn to attention by this, she noticed a small sign near the desk that read “if you have to wait more than 15 minutes please let us know.”  She became upset at having spent an extra 45 minutes of her workday because no one had pointed out the sign or the policy.  Clearly this hospital had identified some glitches in its process to post this sign. While we want to involve patients, it should not be their responsibility to monitor their wait time.  Why not just scan your waiting room 4 times an hour and mark who is there on a dry erase board? Employees can have all sorts of visible reminders to do this.  Also notify the patients that your goal is to see them in 15 minutes from their check in time. Most people probably never even see the sign.

With another recent case of a kidney transplant mix-up (luckily causing no harm to the patient) we really have to redefine our hospital processes.  We have to involve the patients but by the time the process ends with them, we need to make sure we have made enough hard stops that an error will never reach them.  Some people will report that if the patient helps to stop the error then the redundancy system works.  And signs probably won’t do much good unless they are reviewed and explained. In most cases signs should be a reminder and a redundant communication, not a primary communication.  An error being stopped at that level should be a VERY rare occurrence.  Also to consider is a study by Davis, Sevdalis & Vincent (2011) which found many patient in the UK reluctant to engage in safety behaviors that became more challenging in nature to a doctor or a nurse.

See previous post on TEAM UP with patients from the DOD

Human Factors: information processing

In Human Factors on December 17, 2010 at 6:11 pm

In the Talk Aloud Method of usability, the observer can begin to understand how the user is processing information gained from interacting with the computer software and hardware
designed to improve safety. Situation awareness. Situation awareness refers to the individual’s ability to assess the environment, determine meaning from the perceptions and patterns present and predict events
based on this information (St Pierre, Hofinger & Buerschaper, 2008). Endsley’s three-level model for situation awareness describes it as an aspect of information processing that “follows perception and leads to decision making and action execution” (Salmon, Stanton, Walker, Baber,Jenkins, McMaster, & Young, 2008, p. 300). The layout of a workplace as well as the way in which information is presented can enhance situation awareness (St. Pierre, et al., 2008). This includes the timing of alerts and alarms Read the rest of this entry »

Usability and Safety

In ergonomics, Human Factors, Patient Safety, Resiliency, safety on November 24, 2010 at 2:13 pm

* please watch video at the end of this post*
In reading articles and other literature on safety one will find recommendations based on their strength of effectiveness.
Here is a chart from an article by Stevens, Urmson, Campbell and Damignani (2010):

How it works: A simple safety intervention in a hospital is to have everyone wearing visible picture IDs. Problem: the IDs keep flipping over hiding the face and name of the employee. Solutions from least effective to most effective:

  • put a warning on the non-picture side that says “this side faces in” (safety still depends on human action)
  • train the employees to remember to periodically check to ensure their badge is facing out (safety depends on human memory)
  • put the picture on BOTH sides of the badge so the flipping over does not compromise the safety system (safety achieved from designing forced function!)

We tend to rely too much on training and memory: read more Read the rest of this entry »

Enhancing resilience: Medication Error Recovery

In human error, Human Factors, Resiliency on November 13, 2010 at 5:48 pm

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