Systems thinking and design and human factors Flashcards
Systems thinking definition
An approach to analysis that focuses on the way the systems constituent parts interrelate and influence one another within a whole.
Human factors analysis
Represents science at the intersection of psychology and engineering. Looks at all aspects of a work system to support human performance and safety.
Human factors engineering
Addresses problems by modifying system design to better aid people. James reason said we can’t change the human condition but we can change the conditions under which humans work.
What impacts human performance
We tend to overestimate our abilities and underestimate our limitations.
What are external factors that impact human performance?
Noise, distractions, interruptions, task design, and environmental conditions.
What are internal factors that impact human performance?
Fatigue stress anxiety and depression
The role of people in systems that determine safety
Health literacy of staff, practice norms (alarm fatigue alert overrides) and physical limitations
The role of task in systems that determine safety are these two things
Complexity of actions, sequencing
The role of tools technology and techniques in systems that determine safety for these three things
Complexity of equipment, ergonomic considerations of operating equipment, sufficient training particularly when newly and introduced
The role of the environment and systems that determine safety include
Noise, distractions and interruptions, clutter, proximity of needed tools
The role of the organization and systems that determine safety
Safety culture, financial decisions, operational decisions, policies and procedures
Planning for possible unintended consequences include these seven things
Analysis of current error reports, benchmarking, review of external literature, FMEA, workflow analysis, simulation, pilots small test of change
What’s a type of diagram is used in workflow analysis to redesign process
Spaghetti diagram which can translate to time and money
What are four things about the workflow analysis process
Include all members on the team, map out the current workflow, redesign with a blank page don’t try to modify the process or make assumptions, constant feedback
Workflow analysis caveat include these four things
Look for real and perceived barriers, what will be the unintended consequences, always do a small test of change PDSA/PDCA, did we solve the problem that prompted the event analysis
What is the corner stone of human factors engineering
Standardization
What is auditing the new processes over time and have staff develop new work around the negate the corrective action this is called
Sustainability
What are three things of normalized deviance
Drift, short cuts, continuum of intent
Why does normalized deviance happen (4 reasons)?
Fluctuations in situations within a complex environment, rules violations, competency, personal motivations
How can normalized deviance be identified?
Proactive observation of processes, error reporting and review, performance improvement efforts, complaints
Highly reliable organizations are
Preoccupied with failure
What are the two s words in the first step in highly reliable organization?
Standardize and simplify
You should avoid what and create what in a highly reliable organization
Avoid reliance on memory or vigilance create redundancies as double checks
What should you learn in a highly reliable organization and what should you use
Learn from failure, learn from the expertise of Frontline workers, and use forcing functions/constraints judiciously -where it’s really needed
What is step one in a three step design strategy in a highly reliable organization
simplification and standardization are used to help minimize the chance of process failure
What is step two and a three step design strategy and highly reliable organizations
Controls are applied to help prevent error from occurring in the simplified process
What is step three and a three step design strategy in a highly reliable organization
Errors that nevertheless occur or identified and interrupted before they cause harm.
What is simplification in a highly reliable organization
Eliminating unnecessary steps (waste) in your workflow
What is standardization in a highly reliable organization
Creating predictability and consistency in your workflow
What are five things that aid standardization?
Common equipment, standard order sheets, checklist, feedback of information on compliance, lots of education and some training
What is the step two and a three step design strategy of higher reliability
Application of controls
What are three things that application of controls do
Recognizes the limits of human performance, lowers the risk of failure even with simplification and standardization, minimizes the risk of drift
What are five examples of application of controls
Building decision aids/reminders into the system, leveraging teamwork and communication, making the desired action in the default action, scheduling practices, taking advantage of habits and patterns
In step three in catching errors and mitigating harm how is this accomplished
Accomplished through the use of redundancy tools
What are three characteristics of redundancy tools
Require careful consideration since they do not represent a form of waste, need to be truly independent, must follow with a medication strategy.
When would a system component redesign be possibly indicated
If redundancy is catching a lot of errors getting through
What is the bottom level in the hierarchy of controls in standardization and simplification
Eliminate the opportunity for error
What is the second level in the hierarchy of controls for standardization and simplification
Facilitate make it hard to do the wrong thing, example: crossing arm (trains and cars scenario)
What is the last thing you do in human factors hierarchy of controls
Policies training and inspection
What are three important things in human factors
Eliminate, facilitate, mitigate
