10/21-10/28, System Vs Human Error , Cognitive Factors and Error, - Technology and error

Explain why “human error” as a cause usually leads to ineffective solutions.

An error is not solely caused by the person involved, rather it reflects the reaction of the person with respect to stimuli in the environment

Latent errors

Undetected or overlooked, present in systems for long periods of time, undetected or overlooked, important contributors to human error

Explain why “human error” as a cause usually leads to ineffective solutions.

An error is not solely caused by the person involved, rather it reflects the reaction of the person with respect to stimuli in the environment

Latent errors

Undetected or overlooked, present in systems for long periods of time, undetected or overlooked, important contributors to human error

Differentiate the “blunt end” and “sharp end” of patient care.

Sharp end: the individuals and part of healthcare system in direct contact with patients

Blunt end: Layers of the health care system not in direct contact with patients- this is were latent errors are established

Describe the health care system and explain how it is complex and adaptive.

Physical, cognitive, and organizational artifacts that people interact with:

→Technology, software, medical device

→Person, team, organization

→Procedure, policy, guideline 

→Physical environment 

People= care providers, care workers, patents and their families and friends 

Complex:Many unknowns and interrelated factors that reduce predictability 

Complex technologies, communication barriers, process of care are widely variable, uncertainty regarding patient care, time pressure, highly variable environments, unique patients

Explain how human factors and ergonomics can help prevent system errors.

Understand the domains of the SEIPS 2.0 model and how it could be applied to identify

the root causes of a medication error.

Describe and recognize examples of the medication error prevention “toolbox”

strategies and explain why they are ranked as more or less effective.

Differentiate skill-based, rule-based, and knowledge-based behavior and recognize examples of each

Skill Based	Behavior is highly automatic and learned; routine
Rule based	A familiar problem where a cognitive solution is available in the form of a learned room Person is required to allocate attention to the task and recognize the current conditions and to match to the rule
Knowledge Based	New unfamiliar problem, performance required undivided attention

Describe how cognitive strain is related to the three kinds of behavior

Skill based behaviors have the lowest cognitive strain, knowledge based behaviors have the highest cognitive strain

Categorize a medication error as a slip, lapse, or mistake (rule-based or knowledge-based) and identify the types of prevention strategies best suited to that error type

Slip	Within Skill  based errors →errors usually due to withdrawal of attention
Lapse	Within Skill  based errors More covert error from largely involving failure of memory  Omission associated with an interruption
Mistake	Failure in the judgemental/inferential processes→ Cannot be solved with a skill based behavior  Rule based errors: Mismatching the conditional elements of an internal rule to a situation  Signs→Tell you the rule is good or applicable Countersigns→Tell you the rule does not apply in this situation  Nonsigns→Unrelated noise (can be abundant) Knowledge based mistakes: Lack of comprehension of a system or a problem

Define and recognize examples of cognitive biases that can lead to errors

Selective Attention	Directing our awareness to relevant stimuli while ignoring irrelevant stimuli in the environment  Mistakes will occur if attention is given to the wrong features or not given to the right features
Inattentional blindness	Fail to notice a readily visible yet unexpected visual stimulus 1)Observer fails to recognize a visual event or object 2)Optic stimulus is fully visible 3)Stimulus would be readily identifiable if the observer were to consciously notice it 4)Stimulus is unanticipated and the failure to recognize it steps from a collapse of attention
Availability Heuristic	Think that things that readily come to mind are more common than what is actually the case
Confirmation Bias	People favor info that confirms their existing beliefs or hypothesis

Describe and recognize examples of the two types of technology (enhanced and

replacement)

Enhanced	Replacement
Improves an existing intervention, making it better, faster, or producing more of it	One technology literally replaces another, using entirely different principles, and renders the first one obsolete

Explain the relationship between cognition and the design of tools/technology

Tools and technology should be designed to support the cognitive work of a given task. The design of tools and technology impact how they are used, how the data are interpreted and the decisions that result from that data 

Explain how usability heuristics for designing a user interface support cognitive factors

Applying usability heuristics to user interfaces can support self monitoring for routine behaviors, reduce reliance on memory and direct attention to the most salient information 

Explain why automation should be implemented with caution

Not every task that can be automated with tech should be. Automation can result in a loss of flexibility and result in unintended harm. Automation can also reduce the human users ability to detect failures