Human Factoring Healthcare

2014 ◽  
Vol 3 (1) ◽  
pp. 191-195 ◽  
Author(s):  
Kristen Miller ◽  
Tandi Bagian ◽  
Linda Williams
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Human Factors ◽  
Human Error ◽  
System Level ◽  
Department Of Veterans Affairs ◽  
Just Culture ◽  
Safe Patient Care ◽  
The Individual ◽  
The Impact

Even in a just culture, preventable or avoidable adverse events can often be attributed to a failure to follow recognized, evidence-based best practices or guidelines at the individual and/or system level. Investigations of adverse events have heightened the awareness of the need to redesign systems and processes to prevent human error. Despite the existence of considerable information about how to improve care through the application of human factors, healthcare professionals are not provided a means to ensure sufficient education in healthcare human factors and the impact on patient safety. Additionally, even when existing knowledge is taught, providers are challenged to translate and apply knowledge to affect safe patient care. The Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS) Healthcare Human Factors Modules were designed to address these challenges by combining dissemination of existing knowledge and recent research into accessible, hands-on activities that drive home human factors and patient safety competencies. These modules represent an innovative and engaging way to allow providers and administrators alike the ability to advance the shift to systems thinking through high-impact education.

Challenges towards Design Review due to Cultural and Human Factors

2019 ◽  
Author(s):  
Eric Brehm ◽  
Robert Hertle ◽  
Alastair Soane
Keyword(s):  
Human Factors ◽  
Human Error ◽  
Structural Safety ◽  
Design Review ◽  
Human Errors ◽  
Cultural Challenges ◽  
Harmonization Process ◽  
Building Culture ◽  
The Individual ◽  
The Impact

<p>Design review has proven effective to avoid human errors in the design process. Since human error is the major cause for structural collapse [1], most countries have implemented procedures for design review in their building legislation. These systems represent the lived building culture in each state and thus work differently. Within the European harmonization process, challenges regarding the integration of different building cultures</p><p>have been discovered. These cultural challenges affect structural safety in a wide array of topics, e.g. technical</p><p>approval of building products.</p><p>In this paper, the effect of differences in the building culture and the way they affect structural safety will be investigated. Furthermore, the effect on the individual due to human factors will be examined and assessed. The goal is to provide a better understanding of the impact of cultural differences on the design review procedure and on the individual.</p>

Sharing Lessons Learned to Prevent Incorrect Surgery

2012 ◽  
Vol 78 (11) ◽  
pp. 1276-1280 ◽  
Author(s):  
Julia Neily ◽  
Peter D. Mills ◽  
Douglas E. Paull ◽  
Lisa M. Mazzia ◽  
James R. Turner ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Human Factors ◽  
Lessons Learned ◽  
Veterans Health ◽  
Health Administration ◽  
Nerve Blocks ◽  
Ensure Patient Safety ◽  
The Impact ◽  
Wrong Site

The purpose of this report is to discuss surgical adverse event lessons learned and to recommend action. Examples of incorrect surgical adverse events managed in the Veterans Health Administration (VHA) patient safety system and results of a survey regarding the impact of the surgery lessons learned process are provided. The VHA implemented a process for sharing deidentified stories of surgical lessons learned. The cases are in-operating room selected examples from lessons learned from October 1, 2009, to June 30, 2011. Examples selected illustrate helpful human factors principles. To learn more about the awareness and impact of the lessons learned, we conducted a survey with Chiefs of Surgery in the VHA. The types of examples of adverse events include wrong eye implants, incorrect nerve blocks, and wrong site excisions of lesions. These are accompanied by human factors recommendations and change concepts such as designing the system to prevent mistakes, using differentiation, minimizing handoffs, and standardizing how information is communicated. The survey response rate was 76 per cent (88 of 132). Of those who had seen the surgical lessons learned (76% [67 of 88]), the majority (87%) reported they were valuable and 85% that they changed or reinforced patient safety behaviors in their facility as a result of surgical lessons learned. Simply having a policy will not ensure patient safety. When reviewing adverse events, human factors must be considered as a cause for error and for the failure to follow policy without assigning blame. VHA surgeons reported that the surgery lessons learned were valuable and impacted practice.

Human Factors to Minimize the Human Error and Improving Patient Safety

2011 ◽  
Vol 1 (11) ◽  
pp. 82-86
Author(s):  
Sanjay Saproo ◽  
◽  
Dr. Sanjeev Bansal ◽  
Dr. Amit Kumar Pandey
Keyword(s):  
Patient Safety ◽  
Human Factors ◽  
Human Error

scholarly journals THE FUTURE OF PASSENGER AIR TRANSPORT – VERY LARGE AIRCRAFT AND OUT KEY HUMAN FACTORS AFFECTING THE OPERATION AND SAFETY OF PASSENGER AIR TRANSPORT

2017 ◽  
Vol 12 ◽  
pp. 104
Author(s):  
Petra Skolilova
Keyword(s):  
Human Factors ◽  
Human Error ◽  
Operating Cost ◽  
Aircraft Design ◽  
Air Transport ◽  
Final Decision ◽  
Factors Affecting ◽  
Fuel Burn ◽  
The Future ◽  
The Impact

The article outlines some human factors affecting the operation and safety of passenger air transport given the massive increase in the use of the VLA. Decrease of the impact of the CO2 world emissions is one of the key goals for the new aircraft design. The main wave is going to reduce the burned fuel. Therefore, the eco-efficiency engines combined with reasonable economic operation of the aircraft are very important from an aviation perspective. The prediction for the year 2030 says that about 90% of people, which will use long-haul flights to fly between big cities. So, the A380 was designed exactly for this time period, with a focus on the right capacity, right operating cost and right fuel burn per seat. There is no aircraft today with better fuel burn combined with eco-efficiency per seat, than the A380. The very large aircrafts (VLAs) are the future of the commercial passenger aviation. Operating cost versus safety or CO2 emissions versus increasing automation inside the new generation aircraft. Almost 80% of the world aircraft accidents are caused by human error based on wrong action, reaction or final decision of pilots, the catastrophic failures of aircraft systems, or air traffic control errors are not so frequent. So, we are at the beginning of a new age in passenger aviation and the role of the human factor is more important than ever.

scholarly journals Feasibility of onchocerciasis elimination using a “test-and-not-treat” strategy in Loa loa co-endemic areas

2020 ◽  
Author(s):  
David J Blok ◽  
Joseph Kamgno ◽  
Sebastien D Pion ◽  
Hugues C Nana-Djeunga ◽  
Yannick Niamsi-Emalio ◽  
...  
Keyword(s):  
Adverse Events ◽  
Drug Administration ◽  
Mass Drug Administration ◽  
Treatment Duration ◽  
Loa Loa ◽  
Serious Adverse Events ◽  
Endemic Areas ◽  
The Individual ◽  
The Impact ◽  
Main Strategy

Abstract Background Mass drug administration (MDA) with ivermectin is the main strategy for onchocerciasis elimination. Ivermectin is generally safe but associated with serious adverse events in individuals with high Loa loa microfilarial densities (MFD). Therefore, ivermectin MDA is not recommended in areas where onchocerciasis is hypo-endemic and L. loa is co-endemic. To eliminate onchocerciasis in those areas, a test-and-not-treat (TaNT) strategy has been proposed. We investigated whether onchocerciasis elimination can be achieved using TaNT and the required duration. Methods We used the individual-based model ONCHOSIM to predict the impact of TaNT on onchocerciasis microfilarial (mf) prevalence. We simulated pre-control mf prevalence levels from 2-40%. The impact of TaNT was simulated under varying levels of participation, systematic non-participation and exclusion from ivermectin due to high L. loa MFD. For each scenario, we assessed the time to elimination, defined as bringing onchocerciasis mf prevalence below 1.4%. Results In areas with 30-40% pre-control mf prevalence, the model predicted that it would take between 14 and 16 years to bring the mf prevalence below 1.4% using conventional MDA, assuming 65% participation. TaNT would increase the time to elimination by up to 1.5 years, depending on the level of systematic non-participation and the exclusion rate. At lower exclusion rates (≤2.5%), the delay would be less than six months. Conclusions Our model predicts that onchocerciasis can be eliminated using TaNT in L. loa co-endemic areas. The required treatment duration using TaNT would be only slightly longer than in areas with conventional MDA, provided that participation is good.

Patient Safety/Quality Improvement Primer, Part III: The Role of Simulation

2021 ◽  
pp. 019459982110133
Author(s):  
Ellen S. Deutsch ◽  
Sonya Malekzadeh ◽  
Cecelia E. Schmalbach
Keyword(s):  
Patient Safety ◽  
Quality Improvement ◽  
Control Charts ◽  
Neck Surgery ◽  
Resident Training ◽  
Statistical Process ◽  
Ensure Patient Safety ◽  
Statistical Process Control Charts ◽  
The Individual ◽  
The Impact

Simulation training has taken a prominent role in otolaryngology–head and neck surgery (OTO-HNS) as a means to ensure patient safety and quality improvement (PS/QI). While it is often equated to resident training, this tool has value in lifelong learning and extends beyond the individual otolaryngologists to include simulation-based learning for teams and health systems processes. Part III of this PS/QI primer provides an overview of simulation in medicine and specific applications within the field of OTO-HNS. The impact of simulation on PS/QI will be presented in an evidence-based fashion to include the use of run and statistical process control charts to assess the impact of simulation-guided initiatives. Last, steps in developing a simulation program focused on PS/QI will be outlined with future opportunities for OTO-HNS simulation.

Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training

2016 ◽  
Vol 32 (5) ◽  
pp. 480-484 ◽  
Author(s):  
SreyRam Kuy ◽  
Ramon A. L. Romero
Keyword(s):  
Patient Safety ◽  
Resource Management ◽  
Adverse Events ◽  
Critical Incident ◽  
Medical Center ◽  
Crew Resource Management ◽  
Management Training ◽  
Veterans Affairs ◽  
Crew Resource Management Training ◽  
The Impact

The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

2017 ◽  
Vol 26 (4) ◽  
pp. 272-277 ◽  
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Eye Tracking ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Safety Net ◽  
Near Miss ◽  
The Impact ◽  
Risk Processes ◽  
Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

Reducing risk in equine anaesthesia part 2: specific risk factors, human factors and safety checklists

UK-Vet Equine ◽  
2019 ◽  
Vol 3 (4) ◽  
pp. 138-145
Author(s):  
Kate R Loomes
Keyword(s):  
Risk Factors ◽  
Patient Safety ◽  
Human Factors ◽  
General Anaesthesia ◽  
Human Error ◽  
Inherent Risk ◽  
Specific Risk ◽  
Risk Knowledge

Performing general anaesthesia in horses carries an inherent risk. Knowledge of the physiological, pharmacological and practical considerations unique to horses is important to be able to minimise this risk and to address complications should they arise. This article discusses the physiological considerations of subsets of the equine population; aspects of human and patient safety; and methods to reduce human error.

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