Human Error in Medicine Flashcards
Human error has been responsible for 70% of what type of accidents?
Airline
The discipline that deals
with the causes and effects of human error?
human factors engineering (HFE)
How many Americans die each year as a result of medical errors?
44,000 – 98,000
What is the 8th leading cause of death?
Medical mistakes
When we interact with machines or complex systems, we frequently do things contrary to our intentions. This can result in…
Inconvenience or Catastrophe
Failure to perform an intended action. It is not defined by an adverse or serious outcome.
Error
An unplanned, unexpected, and undesired event. An adverse outcome after an error must be construed to be what?
Accident
Percentage of perfusion accidents due to human error?
72.3%
Percentage of perfusion accidents due to equipment failure?
19.5%
Percentage of perfusion accidents due to indeterminate?
8.2%
Input data is are incorrectly perceived, an incorrect intention formed, and the wrong action performed.
Misperceptions
Input data correctly perceived, an incorrect intention is formed, and the wrong action performed.
Slip
Mistake
Input data correctly perceived, correct intention is formed, and the wrong action performed.
Slip
An error which arise from processes inside the actor. The elimination/reduction of such errors must involve psychology, physiology or neurology.
Endogenous Error
An error which arise from processes outside the actor. Elimination/reduction of these errors must involve engineering and design of objects and work environment
Exogenous Error
leaving out a step
Error of Omission
forgetting to turn on the gas during initiation
adding inappropriate step
Error of Commission
Hitting my thumb with a hammer
inappropriate adding of a step normally appropriate to a process
(Opening venous line during sucker bypass)
Error of Repetition
Opening the venous line during sucker bypass
correct steps, but in wrong order
Error of sequence
Weaning: turning down flow, then increasing the bite on the venous clamp
Error of Substitution
omission + commission
This failure type are unsafe acts committed by those at the “sharp end” of the system
(air traffic controllers, pilots, anesthesiologists, perfusionists, etc…)
Active Failures
- immediate, short-term effects
- Usually are unique to an event
This failure type arise from fallible decisions, usually Created by “top-level” decision makers, those at the “blunt end” (supervisors, managers, administrators). Their consequences may lie dormant for a long time, becoming evident only when they combine with local triggering factors (i.e., active failures, technical faults, atypical system states, etc…)
Latent Failures
- Can lie dormant for many years
- Can contribute to many different events
6 Defenses that are measures to protect against hazards and to mitigate the consequences of human failures.
Protection Detection Warning Recovery Containment Escape
Name 2 Unintended actions?
Slips
Lapses
Slips
Attentional
intrusions
omissions
Lapses
Memory losing place omitting steps forgetting intentions
Name 2 intended actions?
Mistakes
Violations
Mistakes
Rule-based
Knowledge based
Violations
Routine
Optimizing
Exceptional
Sabotage
6 Error-producing conditions?
- high workload
- inadequate knowledge, ability, or experience
- inadequate supervision/instruction
- stressful environment
- mental state (fatigue, boredom, extreme anxiety)
- change
7 Violation-producing conditions
- lack of safety culture
- lack of concern
- poor morale
- violation-condoning norms
- macho attitudes
- poorly expressed rules
- priority violation
Perfusion Incident rate ?
1 in 1,000 cases
Human error = 72.3%
Equipment Failure = 19.5%
All human beings, regardless of their skills, abilities, and specialist knowledge, make fallible decisions and commit unsafe acts. The human propensity for committing errors and violating safety procedures can be moderated by what 4 items?
Selection
Training
Well-designed equipment, and good Management,
But, it can NEVER be entirely eliminated.
Can the human propensity for committing errors and violating safety procedures ever be completely eliminated ?
NO
No matter how well designed, constructed, operated, and maintained they all may be, all man-made systems possess ____ ____ in some degree. These failures are analogous to resident pathogens in the human body that combine with local triggering factors (i.e., life stresses, toxic chemicals etc…) to overcome the immune system. Like cancer and cardiovascular disease, disasters in well-defended systems do not arise from single causes. They occur because of the adverse ____ of several factors, each necessary, but none sufficient to breach the defenses.
latent failures
conjunction
All human endeavors involve some measure of ____ . In many cases, the local hazards are well understood and can be guarded against by a variety of technical or procedural counter-measures. But no one can foresee all the possible accident scenarios, so there will always be chinks in this protective armor.
risk
“Even when fatigued, I perform effectively during critical phases of operations/patient care”.
Who agreed with this statement?
Who disagreed with this statement?
Disagreed: Pilots @ 26%
Agreed: Surgeons @ 60%
“Junior team members should not question the decisions made by senior staff members”.
Who agreed with this statement?
Who disagreed with this statement?
Disagreed: Surgeons @ 55%
Agreed: Pilots @ 97%
“The level of teamwork and communication
with consultant surgeons is high”.
Who agreed with this statement?
Who disagreed with this statement?
Disagreed: Surgical Residents @ 73%
Surgical nurse @ 28%
Anes. Residents @ 10%
Agreed: Surgeons @ 64%
The best perfusionists develop what behind the pump ?
A curious and suspicious attitude
Human performance is best at what stress level ?
Moderate Stress
I have anxiety, stress, and high interest during this ECMO phase.
Phase I (Beginning)
The novelty is gone and I feel “hey this isn’t so tough” during this ECMO phase.
Phase II ( Middle)
I am appropriately vigilant, aware of the unpredictable nature of high tech medicine during this ECMO phase.
Phase III (Maturity)
Errors can be moderated by:
- Good training
- Continuing education
- Wet-labs/emergency drills
- Appropriate procedures
- Checklists
- Protocols
- Adoption of new techniques
- Well-designed human-machine interface
- Identifying potential “latent” error
The holes in the defenses are created by what?
- Active failures &
* Latent conditions
Low-end solutions focus on ?
those who committed errors or violations.
High-end solutions focus on?
systemic problems (latent conditions).
