Systems thinking and design and human factors Flashcards

1
Q

Systems thinking definition

A

An approach to analysis that focuses on the way the systems constituent parts interrelate and influence one another within a whole.

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2
Q

Human factors analysis

A

Represents science at the intersection of psychology and engineering. Looks at all aspects of a work system to support human performance and safety.

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3
Q

Human factors engineering

A

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.

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4
Q

What impacts human performance

A

We tend to overestimate our abilities and underestimate our limitations.

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5
Q

What are external factors that impact human performance?

A

Noise, distractions, interruptions, task design, and environmental conditions.

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6
Q

What are internal factors that impact human performance?

A

Fatigue stress anxiety and depression

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7
Q

The role of people in systems that determine safety

A

Health literacy of staff, practice norms (alarm fatigue alert overrides) and physical limitations

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8
Q

The role of task in systems that determine safety are these two things

A

Complexity of actions, sequencing

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9
Q

The role of tools technology and techniques in systems that determine safety for these three things

A

Complexity of equipment, ergonomic considerations of operating equipment, sufficient training particularly when newly and introduced

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10
Q

The role of the environment and systems that determine safety include

A

Noise, distractions and interruptions, clutter, proximity of needed tools

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11
Q

The role of the organization and systems that determine safety

A

Safety culture, financial decisions, operational decisions, policies and procedures

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12
Q

Planning for possible unintended consequences include these seven things

A

Analysis of current error reports, benchmarking, review of external literature, FMEA, workflow analysis, simulation, pilots small test of change

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13
Q

What’s a type of diagram is used in workflow analysis to redesign process

A

Spaghetti diagram which can translate to time and money

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14
Q

What are four things about the workflow analysis process

A

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

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15
Q

Workflow analysis caveat include these four things

A

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

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16
Q

What is the corner stone of human factors engineering

A

Standardization

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17
Q

What is auditing the new processes over time and have staff develop new work around the negate the corrective action this is called

A

Sustainability

18
Q

What are three things of normalized deviance

A

Drift, short cuts, continuum of intent

19
Q

Why does normalized deviance happen (4 reasons)?

A

Fluctuations in situations within a complex environment, rules violations, competency, personal motivations

20
Q

How can normalized deviance be identified?

A

Proactive observation of processes, error reporting and review, performance improvement efforts, complaints

21
Q

Highly reliable organizations are

A

Preoccupied with failure

22
Q

What are the two s words in the first step in highly reliable organization?

A

Standardize and simplify

23
Q

You should avoid what and create what in a highly reliable organization

A

Avoid reliance on memory or vigilance create redundancies as double checks

24
Q

What should you learn in a highly reliable organization and what should you use

A

Learn from failure, learn from the expertise of Frontline workers, and use forcing functions/constraints judiciously -where it’s really needed

25
Q

What is step one in a three step design strategy in a highly reliable organization

A

simplification and standardization are used to help minimize the chance of process failure

26
Q

What is step two and a three step design strategy and highly reliable organizations

A

Controls are applied to help prevent error from occurring in the simplified process

27
Q

What is step three and a three step design strategy in a highly reliable organization

A

Errors that nevertheless occur or identified and interrupted before they cause harm.

28
Q

What is simplification in a highly reliable organization

A

Eliminating unnecessary steps (waste) in your workflow

29
Q

What is standardization in a highly reliable organization

A

Creating predictability and consistency in your workflow

30
Q

What are five things that aid standardization?

A

Common equipment, standard order sheets, checklist, feedback of information on compliance, lots of education and some training

31
Q

What is the step two and a three step design strategy of higher reliability

A

Application of controls

32
Q

What are three things that application of controls do

A

Recognizes the limits of human performance, lowers the risk of failure even with simplification and standardization, minimizes the risk of drift

33
Q

What are five examples of application of controls

A

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

34
Q

In step three in catching errors and mitigating harm how is this accomplished

A

Accomplished through the use of redundancy tools

35
Q

What are three characteristics of redundancy tools

A

Require careful consideration since they do not represent a form of waste, need to be truly independent, must follow with a medication strategy.

36
Q

When would a system component redesign be possibly indicated

A

If redundancy is catching a lot of errors getting through

37
Q

What is the bottom level in the hierarchy of controls in standardization and simplification

A

Eliminate the opportunity for error

38
Q

What is the second level in the hierarchy of controls for standardization and simplification

A

Facilitate make it hard to do the wrong thing, example: crossing arm (trains and cars scenario)

39
Q

What is the last thing you do in human factors hierarchy of controls

A

Policies training and inspection

40
Q

What are three important things in human factors

A

Eliminate, facilitate, mitigate