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Applying Human Factors to Improve Patient Safety
Matt Scanlon, MD, CPPS Professor of Pediatrics-Critical Care
Medical College of Wisconsin
Founding and Executive Member
Paediatric International Patient Safety and Quality
Community
[email protected]
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qu ves
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The Human Factor X
Human Factors Engineering
(Ergonomics)
Somebody made a mistake
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5
productividad
calidad eficiencia
seguridad
Comportimiento humano
Goals of Human Factors
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ORGANIZATION
ENVIRONMENT TOOL &
TECHNOLOGY
TASKS
ENVIRONMENT
PEOPLE
Safety and
Harm
Substitution Test for systems problems
Work Systems Model
Carayon 1989, 2000, 2000
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Work System Process Outcomes
Carayon 2006
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8
Cuando usted sabe cuntos resultados estn
fuera de rango , que levante la mano
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intntalo de nuevo
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11
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14.5 mg of morphine sulfate in 2 mg/2mL syringes
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106,065 medication orders
99,340 alerts
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Bair Hugger
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What about Lean/Six Sigma?
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Patient Safety Safety Science
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The Perspective of Safety-I
I attribute it to human error. But then I attribute everything
to human error
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assumptions in safety-I
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view from safety-II
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assumptions in safety-II
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empirical support
direct observations of CV surgery
surgeons w/ best results
had just as many untoward
events as those w/ worst
but they had better means of detection greater repertoire of
responses
de Leval 2000
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but they had better means of detection greater repertoire of
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Learning in Safety I v II N
um
ber
of
Ou
tco
mes
Range of OutcomesPoor Excellent
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What is the relationship between the activities of Safety and
Quality?
Safety I and Quality: Reduce (non-value added?)
variation
Safety II: Promote adaptability
(resilience)
Both necessary; Systems and context determine how much of
either
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Resilient Systems
must respond in an appropriate manner in real time (including
when coping with the unexpected)
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Resilient Systems
must have adequate surveillance capability
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Resilient Systems
must be forward looking, anticipating what can happen and
preparing responses
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Resilient Systems
must learn from experiences
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Resilient Systems
Have the ability to make sacrificing decisions (such as
accepting a short term loss in exchange long term success,
or cutting ones losses)
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ORGANIZATION
ENVIRONMENT TOOL &
TECHNOLOGY
TASKS
ENVIRONMENT
PEOPLE
Safety and
Harm
Carayon 1989, 2000, 2000
