Human Factors Engineering and Patient Safety Faculty Development

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Human Factors Engineering and Patient Safety
Faculty Development

• John Gosbee, MD, MS
• VA National Center for Patient Safety
• John.Gosbee_at_med.va.gov www.patientsafety.gov

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Location in the Curriculum Toolkit

• Content
• Pt. Safety Introduction
• Human Factors Engineering
• Pt Safety Interventions
• Root Cause Analysis

• Instructor Preparation
• Swift and Long Term Trust
• Selling the Curriculum to Peers and Leadership
  for Lasting Change
• Etc.

• Alternative Education Formats
• Pt Safety Case Conference (MM)
• Pt Safety on Rounds (Modulettes)
• One-month Elective
• Etc.

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Objectives

• Understand how human factors engineering (HFE) is
  a useful problem-solving approach for patient
  safety
• Introduce how demonstration of HFE principles
  helps
• Turn learners brains around 180 degrees
• At the same time teach them safety content
• Demonstrate how HFE helps improve analysis and
  development of lasting remedies (interventions)

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Overview

• Rationale for including HFE
• Basics of human factors engineering (HFE)
• Context of including HFE into other patient
  safety modules
• Preliminary evaluation of HFE modules

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Where has HFE been taught in Healthcare Academia
and VA?

• 1994 2000
• Michigan St Univ 200 Medical Students and
  Residents
• Western Mich Univ 400 Nursing and allied
  health students
• Ferris St Univ 10 PharmD students
• 1999 Present
• 300 VA residents and students at 6 VAs and
  universities
• 1400 physicians, nurses, managers from all 160
  VAs
• Gosbee JW. Human Factors Engineering is the
  Basis for a Practical Error-in-Medicine
  Curriculum. In C. Johnson (Ed.) Tech Rpt G99-1.
  Univ. of Glasgow.
• http//www.dcs.gla.ac.uk/johnson/papers/HECS_99/
  Gosbee.htm

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Recall goals of the VA Curriculum

• Residents are active agents of change towards
  systems and quality approach away from blame
  and train model
• 2. Residents incorporate understanding of human
  performance and high reliability organizations
  into
• - Patient care
• - Patient safety activities
• 3. VAs help affiliated residency programs
  provide great education (as outlined in ACGME
  core competencies)

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Where does HFE fit into Objectives of the
Curriculum

• Understand the scope and gravity of patient
  safety events (adverse events)
• Know theoretical practical reasons why blame
  and train approaches fail
• Become familiar with the basics of safety and
  human factors engineering
• Understand importance of discovering root cause
  towards developing proper interventions
• Become familiar with human factors engineering
  techniques that determine root causes and how
  this is crucial to the design of effective
  interventions
• Understand major categories of patient safety
  interventions, as well as the limitations and
  pitfalls of automation as a countermeasure

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What is Human Factors Engineering?

• Designing systems devices, software, and tools to
  fit human capabilities and limitations
• Using methods to gather unique information on
• Hidden needs of the end-user
• Unexpected interactions between the system and
  the end-user
• Taking advantage of knowledge bases about
  human-system interaction

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Human Factors Model

• Psychomotor
• Hand
• - Feet

• Input Devices
• Buttons
• - Foot pedal

INTERFACE
Senses - Vision - Hearing
Output - CRT - Sound
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Broad Impact of Human Factors Engineering

• Aviation (since 1940s)
• Nuclear Power
• Space flight
• Computer software and hardware (Xerox PARC 1970s)
• Consumer products (Palm Pilot, Snakelight)
• Railroad, motor vehicle, farm machinery, etc.

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Origin of Human Factors Engineering material?

• Experience of Introductory HFE courses to
• Engineers who are forced to learn
• Changing safety mindset of engineers
• Experience of HFE consultants or pioneers
• Doing change management for a whole company
• Even to level of high school students (see NY
  high school psychology curriculum)
• Experience of VA NCPS teaching
• Techniques and examples that allow them to
  integrate it
• Experience of John Gosbee mentoring others
• Techniques or examples that people say changed
  their life

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Radar Scope to Detect enemy ships
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Performance Graph (curve)
100
90
80
70
Performance
1
2
3
4
Time (hours)
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Performance Graph (curve)
100
90
80
70
Performance
1
2
3
4
Time (hours)
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How can we move the curve upwards?
100
90
80
70
Performance
1
2
3
4
Time (hours)
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Demonstration Stroop Effect
Row 1
Row 2
Row 3
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Now, State the Color of the Text as Fast as You
Can
Yellow
Green
Red
Blue
Row 1
Green
Red
Blue
Yellow
Row 2
Red
Blue
Yellow
Green
Row 3
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Again, State the Color of the Text as Fast as
You Can
Red
Blue
Green
Yellow
Row 1
Yellow
Green
Red
Blue
Row 2
Blue
Yellow
Green
Red
Row 3
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Tell the nursing student to attach the oxygen
mask and tubing to the green spigot
Patient Safety Correlation
For further info, see http//faculty.washington.ed
u/chudler/words.htmlseffect
J. Ridley Stroop (1935) Studies of
Interference in Serial Verbal Reactions. Journal
of Experimental Psychology, vol 18, 643-662
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Knee-jerk vs. HFE-based Remedy
Better
Make sure to use the correct color Adaptor!?
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HFE ExamplePatient Controlled Analgesia (PCA)
Pump Redesign
Existing Design
New Design
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PCA Programming Sequence Redesign
Existing Design
New Design
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User population

• Tested with 2 user populations
• Novice users
• Nursing students n12
• Expert users
• Recovery Room Nurses n12

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Usability Evaluation of a PCA Pump Measurements

• Programming Errors Measured
• Quantity
• Severity
• Subtask classification
• Performance Measured
• Programming Time
• Task completion time
• Subtask completion time
• Mental Workload Ratings ? NASA-TLX
• Subjective Preference ? Questionnaire

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PCA Pump Errors - Results

• New Interface
• 55 reduction in number of errors
• Zero errors in entering drug concentration
• Old interface
• 8 drug concentration errors were made
• 3 of these were not detected and were left
  uncorrected
• Mode Errors
• Old interface errors involved selecting the wrong
  mode (11 errors, 9 of which were eventually
  corrected
• With the new interface, only 3 such mode
  selection errors occurred, all of which were
  eventually corrected

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Other Results

• Task Completion Time
• 11/12 end-users faster with new interface
• Average 18 faster
• No difference in Subjective Workload
• Over 90 preference for new interface

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How Big a Role is HFE?

• 99 of all adverse events?
• See recent analysis of 252 laparoscopic bile duct
  injury cases (Way LW, et al. Ann Surg.
  2003237(4) 460-9)
• One in a Thousand or One in Five?
• This is what many say to me when I propose
  inclusion of HFE
• Recent JAMA article (Samore)
• From 0.1 to 17 of all admissions to 3 different
  hospitals in Utah
• From self report (technique) to observation to
  trigger tools

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Healthcare SystemsRange from the Simple to
Complex

• Syringe, catheter bag and its tubing
• O2 cylinder, ECG machine, IV pump
• Code cart, anesthesia work station
• Hospital computer system
• MRI control room and suite
• ICU, ED, OR

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Human Factors Engineering is about the whole
system

• Whats the design of the training and education
• Labeling and instructions attached to device
• Policy and procedures?
• Layout and structure of
• The room
• The overall environment

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Human Factors Engineering and Your World

• Anesthesiology
• Design of alarms, monitors, and safety systems
• Emergency Medicine
• Design of decision-making tools and monitoring
• Surgery
• Design of hand tools and visualization devices
  (laparoscopy)

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Who else includes HFE?

• Nursing Schools (as part of survey or informatics
  courses)
• Western Michigan University (since 1995)
• University of Missouri (2003)
• Nursing board for healthcare informatics
  certification
• Pharmacy Schools (as part of medication safety
  courses)
• University of Wisconsin (since 2002)
• Ohio State (2000?, contact is Phil Schneider)
• Medical Schools (as part of patient safety)
• UC-San Diego (contact Matt Weinger)
• University of Miami

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Conclusions

• Human factors engineering is to patient safety as
  microbiology is to infection control
• HFE knowledge base is rare in healthcare
• Only a few formal or funded efforts to change
  this
• Unsure whether simple efforts to teach HFE are
• Simplistic
• Stay with the learner
• Next HFE Exercise!

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HFE Exercise Groups of 3-4

• One person as Director
• Remind participant to think aloud
• Lead subsequent discussion
• One person as Participant
• Use the device/object in the way you think it
  should be used
• 1-2 Observers
• Actions, comments, swear words, facial expressions

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HFE Exercise (Continued)

• Summarize HFE issues
• Summarize re-design ideas
• Identify one item in Hands-On Museum that is
  correlate to some of your findings