2. • In last 100 years, human life expectancy
increased by 25 years in developed countries due
to –
– immunisation
– motor vehicle safety & workplace safety
– control of infectious disease
– declines in deaths from heart disease and stroke
– safer and healthier foods
– healthier mothers and babies, family planning
– the recognition of tobacco as a health hazard.
3. Two big challenges in healthcare
• Greater demand due to greater volumes of
patients who are older and have more chronic
diseases often requiring multidisciplinary care
• An increasing volume of treatment options
often of increasing complexity and cost
4. HUMAN FACTORS
• Healthcare largely depends on direct human
interventions.
• Human factors (HF) is the study of –
– the interrelationship between humans, the tools
they work with & the environment in which they
work
– The SHELL model was designed to help
understand these relationships
5.
6. • The SHELL concept is named after the initial
letters of its components – Software,
Hardware, Environment and two Livewares.
• In the centre of the model is the human
operator, or the first Liveware, represented by
‘L’.
• This may be any individual whose job is
relevant to patient care.
7. • It is the most flexible component in the
system but may be unpredictable due to
individual factors such as personality,
motivation, stress tolerance, skills, knowledge
and attitudes.
8. • The first interface, Liveware–Hardware, has
much to do with the ergonomic design of the
tools and medical devices that are used and
designed in such a way that they should, for
example, make it difficult for the user to make
a mistake.
9. • The Liveware–Software interface
encompasses the non-physical aspects of the
system such as manuals, checklists and
computer programs. An adequate Liveware–
Software interface should produce a situation
where procedural omissions are difficult to
make.
10. • The Liveware–Environment interface may
include stressors in the physical environment
that have to be coped with such as noise, poor
acoustics and overcrowding.
• The second Liveware–Liveware interface is the
interface of interpersonal communication. It
embraces concepts such as team coordination,
conflict resolution and the continuity of
information flow in the care of patients
11. • In the SHELL model diagram the edges of the
blocks are uneven. This is to illustrate the fact
that the interdependent components are
constantly changing and will never match
perfectly.
• HF are concerned with minimising the
mismatch between the different components.
12. • HF training in healthcare enhances clinical performance
through an understanding of the effects of teamwork,
tasks, equipment, workspace, culture and organisation
on human behaviour in clinical settings.
• An HF approach to patient safety differs from traditional
safety training in that the focus is less with the technical
knowledge and skills required to perform specific tasks,
but rather with the cognitive and interpersonal skills
needed to effectively manage a team-based, high-risk
activity
13. Crew Resource Management (CRM)
training = HF training
• cognitive skills are the mental processes used for gaining and
maintaining situational awareness, for solving problems and making
decisions.
• Interpersonal skills are the communications and behavioural
activities associated with teamwork.
• CRM training develops effective communication skills and a
cohesive environment among team members, and builds an
atmosphere in which all personnel feel empowered to speak up
when they suspect a problem.
• Team members are trained to cross-check each other’s actions,
offer assistance when needed and address errors in a non-
judgmental fashion. Debriefing and providing feedback are also
components of CRM training.
• It also emphasises the role of fatigue, perceptual errors (such as
misreading monitors or mishearing instructions) and the impact of
management styles and organisational cultures.
14. Patient Safety
• Medicine will never be a risk-free.
• From the beginning of training, doctors are
taught that errors are unacceptable.
• philosophy of “primum non nocere” means
“first, do no harm”
15. Patient safety – challenges
• dealing with unsafe practices
• incompetent healthcare professionals
• poor governance of healthcare service
delivery
• errors in diagnosis and treatment
• non-compliance with accepted standards
• When errors do occur there continue to be
inadequate systems in place
16. • The aviation and nuclear industries have a much
better safety record than healthcare.
• Report published in 1999 - ‘To Err is Human:
Building a Safer Health System’, with
– statistics that there were between 44,000 and
98,000 preventable deaths annually due to medical
error in American hospitals with some 7,000
preventable deaths related to medication errors
alone
17. • The World Health Organization (WHO)
estimates that, even in advanced hospital
settings, one in ten patients receiving health
care will suffer preventable harm.
• if medical error was a disease it would rank as
the third leading cause of death in the United
States after heart disease and cancer
18. Patient safety incidents
• An adverse event –
– An incident that results in harm to the patient
• A near miss –
– An incident that could have resulted in unwanted
consequences but did not, either by chance or
through a timely intervention preventing the
event from reaching the patient
19. • A no-harm event –
– An incident that occurs and reaches the patient
but results in no injury to the patient. Harm is
avoided by chance or due to mitigating
circumstances
20. Factors contributing to patient safety
incidents
• Human factors
– Inadequate patient assessment; delays or errors in
diagnosis
– Failure to use or interpret appropriate tests
– Error in performance of an operation, treatment or test
– Inadequate monitoring or follow-up of treatment
– Deficiencies in training or experience
– Fatigue, overwork, time pressures
– Personal or psychological factors (e.g. depression or drug
abuse)
– Patient or working environment variation
– Lack of recognition of the dangers of medical errors
21. • System failures –
– Poor communication between healthcare providers
– Inadequate staffing levels
– Disconnected reporting systems or over-reliance on
automated systems
– Lack of coordination at handovers
– Drug similarities
– Environment design, infrastructure Equipment failure
due to lack of parts or skilled operators
– Cost-cutting measures by hospitals
– Inadequate systems to report and review patient safety
incidents
22. • Medical complexity –
– Advanced and new technologies
– Potent drugs, their side effects and interactions
– Working environments – intensive care, operating
theatres
23. Understanding Patient Safety Incidents
• The Person Approach
• The system Approach
– Heinrich’s safety pyramid
– Swiss cheese model
24. The person approach
• Humans are fallible and that errors can occur through
– doing the wrong thing –errors of commission
– failure to act – errors of omission
– errors of execution – doing the right thing incorrectly
• These principles also tell us that, by understanding the
reasons why adverse events and near misses occur and
by applying the lessons learnt from past events, future
errors can be prevented.
• However, for most errors the person approach on its own
tends to blame the individual and restricts learning.
25. The system approach
• Health systems add complex organisational structures
to human fallibility thus substantially increasing the
potential for errors.
• A systems approach to error recognises that adverse
events rarely have a single isolated cause and that they
are best addressed by examining why the system failed
rather than who made the mistake.
• James Reason, former Professor of Psychology at
Manchester University, has stated that, “We cannot
change the human condition but we can change the
conditions under which people work so as to make
error less provoking.”
27. • Developed in 1931, Heinrich’s safety pyramid
theorised that unsafe acts or near misses lead
to minor injuries and, over time, to a major
injury.
• The accident pyramid proposes that for every
300 near misses there are 29 minor injuries
and one major injury.
28. • Risk assessment, which is a step in risk
management that calculates the value of risk
related to a situation or hazard, has shown us
that what prevents patients from being hurt is
not only by reducing the number of mistakes
but rather by increasing the number of
defences set up against the consequences of
mistakes.
29. • The key message is that near misses provide
the best data about the reliability of safety
systems.
• It is, therefore, most important to report near
misses as well as adverse events to ensure
that defences against adverse events are built
and sustained.
31. • Reason’s theory of accident causation- Swiss
Cheese Model is as well known in the aviation
and nuclear power industries as it is in
healthcare.
• This model takes Heinrich’s concept forward and
proposes the notion of active failures – acts that
are committed by those at the coal face such as
slip-ups, lapses or mistakes – and latent
conditions – created by decisions taken at a
higher level within the organisation leading, for
example, to staff shortages or time pressures
32. • Reason hypothesised that all organisations
operating in potentially harmful environments
tend to build up defences against potential
damage and that these defences can be broken
down by active failures or latent conditions.
• Although latent conditions are not harmful in
themselves, they lie dormant within the system
before combining with active failures to bypass
the defences.
33. • The defences in this model are represented as slices of
Swiss cheese. This is because, instead of being intact, they
are, in reality, full of holes or defects that represent either
active failures or latent conditions.
• In addition, these gaps in the defences may not be static
but can open and close and change position over time.
• Danger arises when a set of holes line up for a brief
window, allowing a potential hazard to become a fully
blown accident.
• Each slice of cheese or defence is an opportunity to prevent
an accident and the more slices there are and the fewer
holes the less likely it is that an accident will occur or harm
be done to a patient.
34. • While healthcare workers are often at the
sharp end of an error they are also often error
catchers.
• It is the clinician’s responsibility to observe,
discuss and highlight latent conditions before
adverse events occur and ensure the
appropriate defences are in place.
35. STRATEGIES FOR PATIENT
SAFETY
• International
– WHO has adopted a strong leadership role with
many initiatives aimed at addressing safety
challenges,
– ‘WHO SAVE LIVES: Clean Your Hands campaign’ to
ensure sustainable hand hygiene and which has now
been adopted by almost 18,000 health facilities in
179 countries
– ‘WHO Guidelines for Safe Surgery 2009’ which
includes the Surgical Safety Checklist aimed at
decreasing the incidence of operative complications.
36. • In low- and middle-income countries the WHO
has also identified priority areas for patient
safety such as
– the Pulse Oximetry Project set up to improve
surgical safety
– The Global Initiative for Emergency and Essential
Surgical Care, a collaboration to reduce death and
disability from injuries, pregnancy-related
complications, congenital anomalies, disasters and
other surgical conditions.
37. Resource-rich countries
• Many governments and national organisations in such
countries have developed important strategies aimed at
delivering safety and quality in healthcare.
• These include:
– regulating and licensing of physicians and healthcare institutions
– developing and adopting policies for patient safety and quality
improvement
– providing patient safety education programmes
– instituting national clinical audits
– reporting (and learning from) adverse events
– setting up agencies to resolve concerns about the practice of
doctors by providing case and incident management services
38. Resource-poor countries
• Resource-poor countries share many of the aspirations and challenges
of richer countries.
• However, they also face issues that are different and require different
strategies. The probability of a patient being harmed in hospital is
higher with, for example, the risk of healthcare-associated infection
being as much as 20 times higher than in richer countries.
• At least 50% of medical equipment in resource-poor countries is
unusable or only partly usable and often the equipment is not used
due to lack of parts or necessary skills.
• In some countries, the proportion of injections given with syringes or
needles reused without sterilisation is as high as 70%. Each year,
unsafe
• injections cause 1.3 million deaths, primarily due to transmission of
hepatitis viruses and human immunodeficiency virus.
• Clearly these issues need to be met with a specific range of initiatives.
39. Institutional or hospital
• Team working and training
• Using information technology.
- Paper-based record systems are more
susceptible to errors and permit fewer checks
than electronic systems. There is now good
evidence that the routine use of information and
communication technology (ICT) will contribute
greatly to the use of real time data to support
clinical decisions, thereby supporting healthcare
workers and patients to more easily access
reliable health information and reduce medical
errors
40. PATIENT SAFETY AND SURGEON
• diagnostic and management errors;
• ● resuscitation errors,
• ● prophylaxis errors;
• ● prescription/parenteral administration
errors;
• ● situation awareness, identification and
teamwork errors;
• ● technical and operative errors.
