Perilous Intersection
Efforts to implement systems that anticipate and minimize the chances of human error, such as computer physician order entry and patient bar coding, are attempts to overcome by design those instances where it is possible to place round pegs into square holes.
Given the complexity of the care that we deliver, it is no longer realistic to think that, if you’re smart and conscientious and try hard, things will be OK. All hospitalists will be involved in some sort of bad outcome. It behooves us to accept that approach and design systems that are failsafe.
—Janet Nagamine, MD, hospitalist, Kaiser Permanente, Santa Clara, Calif.
There are some patient safety problems that lend themselves to an epidemiologic approach, such as rates of infection, for instance, where we can see we’ve done something to improve upon those rates. The human factors/ergonomics approach is complementary to that approach. Human factors concepts help us design interventions to prevent those rare errors, for which we don’t have rates or readily obtainable rates. The need is not for one approach or the other. We need both.
—Sanjay Saint, MD, hospitalist, professor of internal medicine, Ann Arbor VA Medical Center, University of Michigan, Ann Arbor, Mich.
Hospitalists can hone a human factors mindset with attention to three areas. First, improve your philosophical and attitudinal view toward what you’re trying to redesign. Second, understand the underlying methodology of the systems that people are troubleshooting in your wards and committees.
Third, explore what HF has found in terms of what works and what doesn’t in patient safety.
Hospitalists are also the recipients of new devices, tools, and technologies for patient care. As members of review committees and procurement committees, hospitalists are asked for input. Knowledge of the nuts and bolts of human factors science will give that input some foundation.
—John Gosbee, MD, MS, human factors engineering and healthcare specialist, University of Michigan, Ann Arbor, Mich.
HF Projects in Motion
A number of hospitalists around the country have or are using HF as part of projects and studies to reduce human errors.
Culture change: In the early 2000s, Janet Nagamine, MD, a hospitalist with Kaiser Permanente in Santa Clara, Calif., and her colleagues took human factors concepts to front-line ICU staff. The human factors training provided a framework to reinforce three basic concepts: all humans make errors; processes can be designed to reduce the possibility of error; and processes can be designed so errors are detected and corrected before causing injury.4 “My colleagues and I knew that the punitive, ‘shame-and-blame’ culture around mistakes and errors were preventing us from identifying problems and moving forward with solutions,” Dr. Nagamine says.
A former ICU nurse and current chair of SHM’s Hospital Quality and Patient Safety (HQPS) Committee, Dr. Nagamine first became involved in HF when she realized how many patients suffered adverse events stemming from poorly designed medical systems. “Some of my most respected mentors were involved in these kinds of cases, and I knew eventually that would be me,” she says. It was a disturbing reality. During her medical training it was drilled into her head smart, diligent doctors would be successful. “But bad things happen in medicine; it’s part of what we do,” she says. “Rather than deny that things will inevitably go wrong, I wanted to study safety science and reliable system design.” She asked herself, how can we prevent the same mistakes from happening to competent people who practice in poorly designed systems? “The patterns are there,” she says. “You can train your eyes to look for vulnerabilities and patterns, then find the solutions.”
