Human Factor Analysis

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Human Factor Analysis
Kathleen Ryan Associate Director, Quality
Safety Branch
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HUMAN FACTORS ANALYSIS AND CLASSIFICATION
SYSTEM(HFACS)
The First Step in Risk Management Process
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A Busy Emergency Department A scenario
ED Beds full Work Overload
Trauma Pt arrives in an Ambulance
ED Reception Communication overflow
MET CALL
Staff called in sick- Agency staff on duty to
backfill Resource crunch
Pt having a cardiac arrest- MET team paged Staff
under work pressure
Visiting Locums Staff not aware of access to
policies and procedures
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Background

• Based on the theory of human error developed by
  James Reason (1990).
• Human factors analysis is a discipline of risk
  management directed at understanding and
  controlling medical device use error.
• Active failures are the actions or inactions of
  operators that are believed to cause the mishap.
  Traditionally referred to as error, they are
  the last acts committed by individuals, often
  with immediate and tragic consequences.(Reason-199
  0).

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Background- Contd

• Drawing upon Reasons (1990) and Weighmann and
  Shappells (2003) concept of active failures and
  latent failures/conditions, a new Department of
  Defence (DoD) taxonomy was developed to identify
  hazards and risks called DoD Human Factors and
  Classification System.
• DoD-HFACS describes four main tiers of
  failures/conditions
• Acts
• Preconditions
• Supervision and
• Organisational Influences

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Key Points

• Two approaches to the problem of human
  fallibility exist the person and the system
  approaches
• The person approach focuses on the errors of
  individuals, blaming them for forgetfulness,
  inattention, or moral weakness
• The system approach concentrates on the
  conditions under which individuals work and tries
  to build defences to avert errors or mitigate
  their effects

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What are the benefits?

• Reduced potential for human error and its
  consequences
• Root cause human factors in incident
  investigation
• Fewer accidents
• Fewer near misses
• Management of organisational change, and safety
  critical communications
• A more productive workforce

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Rules Violation

• Goal conflict and procedural deviance
• Divergence from written guidelines in a need to
  pursue multiple goals goal conflict.
• Contradictory goals are the rule, not the
  exception in complex situations Sidney
  DekkerSurgical waiting list and ED access
  targets V Safety targets
• Rewards what gets rewarded
• Activity or Safety Targets??

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Working towards safety

• Organisations who wish to make progress on safety
  with procedures need to
• Monitor the gap between procedure and practice
  and try to understand why it exists ( and resist
  trying to close it simply telling people to
  comply)
• Help people develop skills to judge when and how
  to adapt ( and resist only telling people they
  should follow procedures).

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• A key to success is integrating human factors
  into existing systems and processes, not trying
  to work it as a stand-alone independent effort.

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Human beings by their very nature make mistakes
therefore, it is unreasonable to expect
error-free human performance. Shappell
Wiegmann, 1997
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What does this mean for the Policy Implementation
Review Group?

• Discussion.
• http//www.health.nsw.gov.au/quality/pirg/index.ht
  ml