Error
• You've carefully thought out all the angles.
• You've done it a thousand times.
• It comes naturally to you.
• You know what you're doing, its what you've been trained
to do your whole life.
• Nothing could possibly go wrong, right ?
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Think Again.
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Cost of Ignoring Human Factors
is
Poor Quality!
• Increased probability of accidents and errors
• Less spare capacity to deal with emergencies
• Increased labor turnover
• Lower productive output
• Increases in lost time
• Higher medical costs
• Higher material costs
• Increased absenteeism
• Low quality work
• Injuries, strains
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Human Error and Accidents
“Human beings by their very nature
make mistakes; therefore, it is
unreasonable to expect error-free
human performance.”
Shappell & Wiegmann, 1997
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Human Error and Accidents
It is not surprising then, that human error has been
implicated in 60-80% of accidents in complex systems.
In fact, while accidents solely attributable to environmental
and mechanical factors have been greatly reduced over
the last several years, those attributable to human error
continue to plague organizations.
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Where do we usually look
to prevent accidents?
Unsafe Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Human Error and Accidents
• Why is the human blamed?
– It is human nature to blame what appears to be the active operator
when something goes wrong.
– Our legal system is geared toward the determination of
responsibility, fault, and blame.
– It is easier for management to blame the worker than to accept the
fact that the workplace, procedure, environment, or system needs
improving.
– The forms we fill out to investigate accidents are usually modeled
after the unsafe act, unsafe condition dichotomy.
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Where should we look to
prevent accidents?
Operating
Environment
Unsafe Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Human Factors Analysis and
Classification System (HFACS)
• HFACS is based on the “Swiss Cheese” model of
error by James Reason (1990)
• Applied to human error analysis in aviation by
– Scott Shapell, Ph.D., Civil Aeromedical Institute and
– Doug Wiegmann, Ph.D., University of Illinois
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
HFACS: Guiding Principles
• Principle 1: Health care systems are similar in nature to
other complex productive systems.
• Principle 2: Human errors are inevitable within such a
system.
• Principle 3: Blaming errors on the human is like
blaming a mechanical failure on the device.
• Principle 4: An accident, no matter how minor, is a failure
of the system.
• Principle 5: Accident investigation and error prevention go
hand-in-hand.
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Breakdown of A Productive System
Organizational Latent Conditions
Inputs
Factors Excessive cost cutting
Economic
inflation Inadequate promotion policies
Few qualified Unsafe Latent Conditions
professionals
Supervision Deficient training program
Regulations
Improper crew pairing
Government
policies Preconditions Active and Latent Conditions
for Poor team work/team resource management
Unsafe Acts Loss of situational awareness
Unsafe Active Conditions
Acts
Incorrect calculation of dosage
Incorrect use of equipment
Failed or
Absent Defenses Did not communicate all needed
information
Did not check device
Adapted from Reason (1990) Accident/Injury
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
ACTS
Errors Violations
Decision Skill-Based Perceptual
Routine Exceptional
Errors Errors Errors
DECISION ERROR
Rule-based Decisions
Unsafe - If X, then do Y
Acts - Highly Procedural
Choice Decisions
- Knowledge-based
Ill-Structured Decisions
- Problem solving
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
ACTS
Errors Violations
Decision Skill-Based Perceptual
Routine Exceptional
Errors Errors Errors
SKILL-BASED
ERRORS
Unsafe
Acts Attention Failures
- Breakdown in information scan
- Inadvertent operation of control
Memory Failure
- Omitted item in checklist
- Omitted step in procedure
- Forgot to check device
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
ACTS
Errors Violations
Decision Skill-Based Perceptual
Routine Exceptional
Errors Errors Errors
PERCEPTUAL
Unsafe ERRORS
Acts
Misread label
Misread chart
Misjudge type of auditory
alarm
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
ACTS
Errors Violations
Decision Skill-Based Perceptual
Routine Exceptional
Errors Errors Errors
ROUTINE (INFRACTIONS)
(Habitual departures from rules condoned by management)
Violation of Orders/Regulations/Standard Operating Procedures
-not checking ID bands
Unsafe -failure to confirm allergy status when ordering antibiotic
Acts in doctors office
-Double check system for blood transfusion
-Side bed rails not raised
Failed to Adhere to policy
Not Current/Qualified for procedure
Improper Procedures
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
ACTS
Errors Violations
Decision Skill-Based Perceptual
Routine Exceptional
Errors Errors Errors
EXCEPTIONAL
(Isolated departures from the rules not condoned
by management)
Violated
- Keep drugs on floor
Unsafe - Extending surgical procedure without patient consent
Acts
Accepted Unnecessary Hazard
Not Current/Qualified for Procedure
Violated standard medical practice
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
PRECONDITIONS
FOR
UNSAFE ACTS
Substandard Substandard
Conditions of Practices of
Operators Operators
Adverse Adverse Physical/
Crew Resource Personal
Mental Physiological Mental
Mismanagement Readiness
States States Limitations
Preconditions
for
Unsafe Acts
ADVERSE MENTAL STATE
Unsafe
Acts Loss of Situational Awareness
Circadian dysrhythmia
Alertness (Drowsiness)
Overconfidence
Complacency
Task Fixation
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
PRECONDITIONS
FOR
UNSAFE ACTS
Substandard Substandard
Conditions of Practices of
Operators Operators
Adverse Adverse Physical/
Crew Resource Personal
Mental Physiological Mental
Mismanagement Readiness
States States Limitations
Preconditions
for
Unsafe Acts
ADVERSE PHYSIOLOGICAL
Unsafe STATES
Acts
Medical Illness
Extreme fatigue
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
PRECONDITIONS
FOR
UNSAFE ACTS
Substandard Substandard
Conditions of Practices of
Operators Operators
Adverse Adverse Physical/
Crew Resource Personal
Mental Physiological Mental
Mismanagement Readiness
States States Limitations
Preconditions
for
Unsafe Acts
PHYSICAL/MENTAL
Unsafe LIMITATIONS
Acts
Lack of Sensory Input
Limited Reaction Time
Incompatible Physical Capabilities
Incompatible Intelligence/Aptitude
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
PRECONDITIONS
FOR
UNSAFE ACTS
Substandard Substandard
Conditions of Practices of
Operators Operators
Adverse Adverse Physical/
Crew Resource Personal
Mental Physiological Mental
Mismanagement Readiness
States States Limitations
Preconditions
for
Unsafe Acts
CREW RESOURCE
Unsafe
Acts MISMANAGEMENT
Not Working as a Team
Poor team Coordination
Improper Briefing Before a Procedure
Inadequate Coordination of
materials/technologies/human resources
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
PRECONDITIONS
FOR
UNSAFE ACTS
Substandard Substandard
Conditions of Practices of
Operators Operators
Adverse Adverse Physical/
Crew Resource Personal
Mental Physiological Mental
Mismanagement Readiness
States States Limitations
Preconditions
for
Unsafe Acts PERSONAL READINESS
Unsafe Readiness Violations
Acts Rest Requirements
Self-Medicating
Poor Judgement
Poor Dietary Practices
Overexertion While Off Duty
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
SUPERVISION
Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem
Unsafe
Supervision
INADEQUATE SUPERVISION
Failure to Administer Proper Training
Preconditions
Lack of Professional Guidance
for
Unsafe Acts
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
SUPERVISION
Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem
Unsafe
Supervision INAPPROPRIATE
PRACTICES
Preconditions Risk without Benefit
for
Unsafe Acts Improper Work Tempo
Poor Team Pairing
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
SUPERVISION
Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem
Unsafe
Supervision FAILED TO CORRECT A
KNOWN PROBLEM
Preconditions Failure to Correct Inappropriate Behavior
for
Failure to Correct a Safety Hazard
Unsafe Acts
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
UNSAFE
SUPERVISION
Planned Failed to
Inadequate Supervisory
Inappropriate Correct
Supervision Violations
Operations Problem
Unsafe
Supervision
SUPERVISORY VIOLATIONS
Preconditions Not Adhering to Rules and Regulations
for Willful Disregard for Authority by
Unsafe Acts Supervisors
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
ORGANIZATIONAL
INFLUENCES
Resource Organizational Operational
Management Climate Process
Organizational
Influences RESOURCE MANAGEMENT
Human
Unsafe
Supervision
Monetary
Equipment/Facility
Preconditions
for
Unsafe Acts
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
ORGANIZATIONAL
INFLUENCES
Resource Organizational Operational
Management Climate Process
Organizational ORGANIZATIONAL
Influences
CLIMATE
Unsafe Structure
Supervision
Policies
Culture
Preconditions
for
Unsafe Acts
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
ORGANIZATIONAL
INFLUENCES
Resource Organizational Operational
Management Climate Process
Organizational
Influences OPERATIONAL
PROCESS
Unsafe
Supervision Operations
Procedures
Preconditions Oversight
for
Unsafe Acts
Unsafe
Acts
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Human Factors has been Effectively
Applied to a Variety of Complex
Systems
• Aviation
– Design of aircraft
– Air Traffic control
• Nuclear Power Plants
• Manufacturing
• Aerospace
– Space station
– Space shuttles
• Anesthesiology
• Computer Systems
• Remotely Operated Vehicles
• Automobiles
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Example System Benefits
• Reduction in reported incidents • Reduced job injuries
and accidents • Reduced patient waiting times
• Reduction in error
• Less “lost” information (forms,
• Improved communication documents, etc)
• Reduced personnel
requirements because tasks • Better handoff
can be more easily • Reduced workload
accomplished • Increased worker job
• Increased customer satisfaction satisfaction
• More quality time with • Etc…
customers
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering
Acknowledgements
• Thanks to Scott Shapell, Ph.D. from the Civil Aeromedical
Institute and Doug Wiegmann, Ph.D. from the University of
Illinois for permission to use and edit slides from their
presentation “A Human Factors Approach to Accident
Analysis and Prevention”.
Copyright 2001 by Dr. Gallimore, Wright State University
Department of Biomedical, Human Factors, & Industrial Engineering