A Systems and Human Factors
Approach to Patient Safety
Carolyn M. Clancy, MD
Director
Agency for Healthcare Research and Quality
2013 International Symposium on Human Factors
and Ergonomics in Health Care
Baltimore, MD – March 11, 2013
Our Health Care System
“Health care is composed of a large set of
interacting systems – paramedic, and
emergency, ambulatory, impatient care, and
home health care; testing imaging
laboratories; pharmacies; and so forth – that
are coupled in loosely connected but intricate
networks of individuals, teams, procedures,
regulations, communications, equipment and
devices that function with diffused
management in a variable and uncertain
environment.”
To Err is Human: Building a Safer Health System
Swiss Cheese Model
of Accident Causation
“Rather than being the main instigators of an accident,
operators tend to be inheritors of system defects created by
poor design, incorrect installation, faulty maintenance and bad
management decisions. Their part is usually that of adding the
final garnish to a lethal brew whose ingredients have already
been long in the cooking.”
Reason, 1990
A Systems and Human Factors
Approach to Patient Safety
 AHRQ Focus and
Priorities
 21st Century Health
Care Needs a Human
Factors Voice
 Where to From Here?
 Q&A
AHRQ Priorities
Patient Safety
 Health IT
 Patient Safety
Ambulatory
Patient Safety
 Safety & Quality Measures,


Organizations
 Patient Safety
Grants (incl.
simulation)
Drug Management, &
Patient-Centered Care
Survey of Patient Safety Culture
Diagnostic Error Research
Medical Expenditure
Panel Surveys
 Visit-Level Information on
Medical Expenditures
 Annual Quality &
Disparities Reports
Effective Health
Care Program
 Comparative
Effectiveness Reviews
 Patient-Centered
Outcomes Research
 Clear Findings for
Multiple Audiences
Other Research &
Dissemination Activities
 Quality & Cost-Effectiveness, e.g.,
Prevention & Pharmaceutical
Outcomes
 U.S. Preventive Services
Task Force
 MRSA/HAIs
AHRQ’s TOP 3 Focus Areas
Patient Safety
• Build a “trustworthy” delivery system,
minimize the impact of adverse events
Quality
• Focus on the National Quality Strategy and
collaboration (HHS, private sector)
“Getting to HOW”
• Practical, evidence-based process
improvements
Translation of Human Factors to
Health Care is Straightforward
 Human Factors as a Discipline
. . . takes into account human strengths and
limitations in the design of interactive systems of
people, tools and technology, and environments to
ensure safety, effectiveness and ease of use
 Human Factors in Health Care
. . . takes into account patient and provider
capabilities in the design of interactive health care
systems of people, devices and technology, and
environments to ensure safety, effectiveness and
ease of delivering care
Teamwork
Expanding Our Overall Capability
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Facilitates shared mental
models
Encourages cross-training and
spread of skills
Increases quality of group
decision-making
Improves cooperation among
specialty areas
Improves job satisfaction
Labor & Delivery Team at North
Bronx Healthcare Network
The New York Public Hospital
System uses TeamSTEPPS
Designing Quality and Safety
Into the Hospital Environment
 Evidence-Based Design
– Build Private Rooms
– Reduce Noise
– Incorporate Nature
– Improve Air Quality
– Encourage Hand
Hygiene
– Improve Wayfinding
– Reduce Walking
Distance
Designing Quality and Safety Into
the Home Care Environment
Health Care Comes Home: The Human Factors
 Systematic investigation of the
role of human factors in home
health care
–
–
–
Very few homes have been
designed for the delivery of
health care
Medical equipment and
technology designed for hospitals
and clinics can be ill-suited for
home use
Includes findings and
recommendations for maximizing
opportunities to improve home
health care
AHRQ-supported study by the Board on Human-Systems Integration of the National Research Council
CUSP Cuts CLABSIs by 40%
in 1,100 Hospital Units
Could there be an equivalent headline for diagnostic error?
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CUSP for CLABSI
Infection prevention
evidence-based practices
Frontline use of checklists
Unit-wide patient safety
culture
Local leader champion
Engaging/educating team
Collecting performance &
outcome measures
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CUSP for DX Error
What should be targeted?
Is there an evidencebase?
What tools are available?
Who owns the problem?
What teams need to be
engaged?
How is diagnostic
performance measured?
Diagnostic Errors: The Next
Frontier in Patient Safety?
“Unfortunately, reliable decision support or feedback systems do not yet exist.”*
 “Triggers” of electronic health records can
help identify potential diagnostic errors in
primary care settings
–
–
–
Refining triggers and reducing false positives led to
detection methods that are far more efficient than conducting
random record review or relying in incident reporting
systems
Usefulness ultimately will depend on continued efforts to
improve their reliability
Primary care reform initiatives should consider these
methods for error surveillance
Electronic Health Record-Based Surveillance of Diagnostic Errors in Primary Care
BMJ Qual Saf 2012;21:93-100.
* Patient Safety Primer: Diagnostic Errors http://psnet.ahrq.gov
Recent Literature Reviews
Find Few Outcome Studies
System-related interventions (Singh et al., 2012)
Our literature review of system-related interventions to
reduce diagnostic error . . . yielded very few empirical
outcome studies. . . Our findings highlight a large gap
between suggested interventions and those that have
been operationalised and evaluated empirically
Cognitive interventions (Graber et al., 2012)
We found that most interventions. . . were simply ideas
or suggestions. Many of these are well conceptualised
and widely endorsed, and seem ripe to be tested in
experimental and real-world clinical settings. . . Our
findings also affirm that the science of outcome
measurement in this area is underdeveloped
The Double-Sided
Nature of Health IT
Purported Benefits
Concerns


Information is the lifeblood
of health care
 With IT, providers can
make better decisions,
avoid duplication of tests
and procedures, and
prevent unwanted
medication interactions
 PCMHs and patient
engagement more easily
realized
 In-home monitoring allows
tracking of patient vitals
and activity
Lack of system
standardization and
interoperability can limit data
sharing
 No central repository to
collect/analyze IT-related
safety glitches
 Most systems are vendor
inspired; user needs,
workflow, and usability
issues have been neglected
 Data entry/retrieval and
awkward interfaces are
issues
Improving Electronic
Medical Records (EMRs)
 As currently designed, EMRs and Health IT

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
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often add another layer of complexity
The shortcomings need continued attention;
vendors and HCOs need to work together on
design, implementation and use issues
Users should be involved at the earliest stages
of design
It’s not just the technology. IT needs to be
aligned with the needs of the greater sociotechnical system – the organizations, people,
and clinical processes that interact and depend
on it
Improvement is a steady, incremental process
Human Factors Design Guide
 Designed to help
designers and developers
of consumer health IT:
–
–
–
User-friendly applications
for a wide range of life
situations
Assist home health
professionals in selecting
tools to complement
professional health care
services
Create new kinds of
consumer health IT and
strategies to increase use
AHRQ-funded study available at: www.nap.edu/catalog.php?record_id=13205
Simulation: A Rapidly Growing
Training & Test Bed Technology
 Learn skills in simulated
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setting first
Risk free environment
for learning
Integration of multiple
skills
Immediate and realistic
feedback; actions have
consequences
Readily available
Simulation Training for CVC Insertion
 Purpose: RCT of Yale medical students on
whether simulation training of ultrasound (US)guided central venous catheter (CVC) insertion
on simulated trainer improves cannulation and
insertion success rates
 Results: 495 CVC insertions by 115 residents
over 21-month period. Successful first
cannulation in 51% of intervention group versus
37% of control group. CVC insertion success for
78% of intervention versus 67% of control group
 Conclusion: Simulation training improved
performance of CVC insertion compared to
control group
Evans LV et al. “Simulation Training in Central Venous Catheter Insertion:
Improved Performance in Clinical Practice.” Acad Med. 2010: 85:1462-1469.
Where to From Here?
 Do more to ensure that new treatments and research
knowledge reach patients and are implemented
correctly
 Improve quality by improving access
 Expand the boundaries of basic science to include
other “basic sciences” (e.g., epidemiology,
psychology, communication, social marketing and
economics)
 More focus on research and delivery of existing
treatments AND interaction between social
determinants and health care
Woolf, S. The Meaning of Translational Research and Why It Matters, JAMA January 2009
Future Needs:
How You Can Help
 Early indicators of likely success
 Share success and productive failures
with www.innovations.ahrq.gov
 Learn from variation in the different
systems
 Help us learn about “spillover” effects –
i.e., does one successful innovation
make the next one easier and faster??
Thank You
AHRQ Mission
To improve the quality, safety,
efficiency, and effectiveness of
health care for all Americans
AHRQ Vision
As a result of AHRQ's efforts,
American health care will
provide services of the highest
quality, with the best possible
outcomes, at the lowest cost
www.ahrq.gov