Human Factors in Incident Analysis

A step away from compsci/digital health in this post…
I have found that doing these posts is actually a good way of forcing myself to write concise notes…and I think it is helping me learn…

So if anybody is reading this…I am doing some incident analysis CPD for nursing at the moment, enjoy!

lect outline

  1. What is Human Factors?
  2. Healthcare challenge
  3. HF approach to root cause analysis
  4. Case studies: using HF to understand risk, inform procurement and respond to near-misses
  5. Barriers to HF adoption in healthcare
  6. HF methods and resources

What is Human Factors?

“concerned with the understanding of interactions among humans and other elements of a system. A profession that applies theory, principles, data, and methods to design in order to optimise human well-being and overall system performance”.

Core skillsets for human factors professionals

  • cognitive ergonomics
    • fit between human cognition and machine/task/environment
  • organisation ergonomics
    • design and optimisation of the overall sociotechnical system….e.g. org structures, policies, processes
  • Physical ergonomics
    • fit between human body responses to physical and physiological work demands

Challenge in healthcare

healthcare = str(complex adaptive system, numerous stakeholders, operates at distinctive yet interconnected levels within the system)

  • health systems don’t react predictably to the same inputs
  • much effort is spent trying to ‘stomp out’ error after harm

Clinical incidents may be caused by:

  • interactions between multiple actors; and not just clinical staff
  • multiple interaction contributing factors from across all levels of the system
  • lack of vertical integration/feedback between hierarchical levels
    (e.g. frontline does not inform higher level decisions, higher level decisions not reflected in practices at frontline).
  • financial, psychological and other pressures
  • gradual erosion of risk controls over time

RCA

undertaken to review care and find out what went wrong and why…

Inefective analyses:
check out: RCA*2 - improving root cause analyses and actions to prevent harm…www.npsf.org
*Includes five rules of causation…

Case Example…NICU heparinised syringes…

“the product is often part of a system composed of other products…end user complexity depends on all products in users environment…”

Example methods and resources…

  1. cognitive walkthrough
  2. observational field work
  3. Simulation studies

good lecture all in all,

very relevant case examples for analysing clinical incidents in the workplace….

Eddie(WTR)