Human Factors

Similar packaging

Human factors definition

• The study of all the factors that make it easier to do the work right away, sometimes known as ergonomics

• Applies wherever humans work

What do human factors acknowledge?

• The universal nature of human fallibility

• The inevitability of error

• Assumes errors will occur

• Designs things in the workplace to try to minimise the likelihood of error or its consequences

• It should be made impossible (or near impossible) to make mistakes

HCP working with complexity

• HCP are quite good at compensating for some of the complex and unclear design of some aspects of the workplace

  • Equipment

  • Physical layouts

• High resilience

2 views on human error - old view

Old view: person approach

• Human error is a cause of accidents

• To explain failure, you must seek human failure

• Find people’s incorrect assessments, wrong decisions & bad judgements

• Get rid of ‘bad apples’ replace with new personnel

2 views on human error - new view

New view: system approach

• Error is a symptom of deeper trouble

• To explain failure, look for the system failure

• Explore how actions and assessments made sense at time

• Replacing people leaves problems in place

Systems-based approach - 2 types of failure

“The system approach isn’t about changing the human condition but rather the conditions under which humans work”

• Active failure (immediate cause)

  • Acts or omissions committed by individuals at the sharp end

• Latent failures (underlying causes)

  • Contributory factors that may lie dormant for days, months, years

  • Often stem from fallible decisions

  • Resident ‘pathogens’ within a system

  • Provide the conditions in which unsafe acts occur

Slips & lapses: errors of action

Active failures (immediate causes)

• When one or more step is executed incorrectly (a slip) or because one or more step is omitted (a lapse)

• Skill-based

• Not amendable to threats or training

  • Capture slips

  • Loss of activation slips

  • Description slips

Mistakes: errors of intention

• A planning failure, where actions go as planned but the plan was bad

• Stems from cognitive breakdowns

• Rule-based or knowledge-based

Example of slip, lapse and mistake

Dual process theory

2 decision making modes:

• System 1 - intuitive, automatic, fast, effortless

• System 2 - analytical, deliberate, slower, effortful

System 1 - contextual cues important

Cognitive biases

• We rely on shortcuts and rules of thumb - known as ‘heuristics’

• Mental shortcuts that are likely to generate acceptable solutions

Specific biases in decision making include:

• Insensitivity biases in decision making include:

• Overconfidence

• Failure to consider alternative options

• Availability heuristic

Managing error

• Slips are inherent to the human condition

• Slips can only be minimised when the processes and systems are made safer

• Mistakes often reflect lack of knowledge and experience

• Improved training and supervision

• Inferior design of a system may predispose to error

• Human failure needs to be engineered out of the systems

  • Automate, standardise, use checklists, decrease number of steps and handoffs, add redundancy (double checks) for high-risk processes

Human errors: facts (inevitable)

• All of use make dumb errors everyday

• No one makes an error on purpose

• Fear of punishment isn’t irrational

• No one admits an error if you punish them for it

• An error isn’t misconduct

• Errors are made for reasons

Summary

• Errors are inevitable

• Medical errors and frequent and significant threats to safe and quality of healthcare

• Be aware of errors that can increase the likelihood of errors

• Attention to human factor principles can lead to a reduction in error or its consequences