Human Factors and Personal Responsibility

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Human Factors and Personal Responsibility

• March 29, 2007
• APIC Spring Seminar
• Suzette Little, MS
• Quality Management Engineer
• Miami Valley Hospital

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When a doctor or nurse can reduce the spread of
antibiotic-resistant bacteria by practicing
simple hand hygiene, accountability should
matter.Donald Goldman, M.D.Senior Vice
President of Institute for Healthcare Improvement
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Human Factors

• How do people think and function on a daily
  basis?
• What are the types of human error?
• Is there an objective way of determining when an
  individual is culpable when an unsafe act occurs?

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Hierarchy of human behavior

• Skill Based Behavior
• Rule Based Behavior
• Knowledge Based Behavior

Rasmussen
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Human error taxonomy

• Slip
• Lapse
• Mistake
• Violation

Reason
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Reason
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Were the actions intended?
Unauthorized substance?
No
Yes
No
Were the consequences as intended?
Yes
Sabotage, malevolent damage, suicide, etc.
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Knowingly violating safe operating procedures?
Unauthorized Substance?
No
Yes
Medical condition?
Yes
No
Substance abuse without mitigation
Substance abuse with mitigation
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Knowingly violating safe operating procedures?
Pass substitution test?
No
Yes
Were procedures available, workable, intelligible
and correct?
Yes
No
Possible reckless violation
System-induced violation
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Pass substitution test?
History of unsafe acts?
Yes
Yes
Deficiencies in training selection or
inexperience?
No
Yes
Possible negligent error
System-induced error
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History of unsafe acts?
No
Yes
Blameless error
Blameless error but corrective training or
counseling indicated
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Hudson Just Culture Model
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Characteristics of a culture that supports safety
Reason and Berwick
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So why dont they wash their hands?

• Time constraints
• Sinks or products inaccessible
• Skin irritation
• Hands dont appear visibly soiled
• Influence of opinion leaders