Assessment of patient safety
management from human factors
perspective
指導教授 ： 李元墩 博士
王正華 博士
博 士 生 ： 周蕙苓
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研究進程
中介變項
領導者價值觀
•重視顧客
•參與與團隊
•持續改善
•資訊分享
領導者特質
經驗開放性
責任
領導者行為
•溝通行為
•團隊設計與
教練行為
組織文化
結果變項
•領導效能
•績效
•品質
「運用階層程序法(AHP)於
醫院護理長甄選模式之建構
與應用」(2011/05/06發表
於博士生論壇)；醫護科技
學刊投稿中
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Introduction
• The pursuit of increased and enhanced safety for
patients in health care has resulted in the patient
safety movement in most industrialized
nations(Richardson & Storr,2010).
• In some developed countries, the occurrence of
adverse events is estimated to stand at 10% of
admissions(Richardson & Storr,2010).
• According to Institute of Medicine (IOM) report that
medical errors kill between 44,000 and 98,000 people
in U.S. hospitals each year(Sammer, Lykens, Singh,
Mains, & Lackan, 2010).
Introduction
• Medical error or patient safety research has
seen an explosion of activity since the
publication of the US Institute of Medicine
(2000) report ‘‘To Err is Human’’.
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Introduction
• In a systemic perspective, the assessment of
the overall safety of an organization involves
the assessment of integrated human and
machine (technical) systems.
• Therefore, it is appropriate to speak about the
entire set of situations and interactions that
may involve humans and machines
(Cacciabuea & Vella, 2010).
Introduction
• Recently, much emphasis has been put on
human factors approaches to patient safety
(Bogner, 1994; Cook, Woods, & Miller, 1998;
Leape, 1994; Wears & Perry, 2002).
• Just as the Institute of Medicine has
recommended the use of human factors
methods and principles to improve health care
(Kohn et al. 2000).
Introduction
• human factors have been studied more
frequently in areas outside health care, eg,
aviation, military, and nuclear power plants
(Ross, 2009).
• The application of HFE in healthcare and
patient safety is not new. In the late 1950s,
such as the study conducted by Safren and
Chapanis (1960), they found that most (90%)
causes of the medication errors fell in human
factors.
Introduction
• However, an understanding of human factors is
lacking for the nursing field (Rivera & Karsh,
2007).
• Therefore, the purpose of this study is to
outline the main human factors that have
relevance for patient safety.
Human factors
• During the last years, different management
systems (e.g. quality management,
environmental management and health or
occupational and health systems management)
have been introduced and brought together
within an integrated management system to
use all possible synergies (Strasser & Zink,
2007).
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Human factors
• Human factors, in terms of the pragmatic
design of the workplace and in close cooperation with technology must strive for the
harmonization of human characteristics with
technical and economic goals and attempt to
reconcile the individuality of people with the
technical and organizational demands of the
world of work.
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Figure 2. Hawkins SHEL model of Human Factors.(Molloy & O’Boyle, 2005)
SHEL Model
• The SHEL model illustrates the interrelationship
of three types of resources and their environment
(E). These three resources include: software (S),
hardware (H), and liveware (L). All of these
resources are continuously interacting within the
context of their environment.
Figure 4. The Swiss Cheese Model (Reason 1990, 1997)
Figure 5 Stages in the development and investigation of an organizational accident
(Reason 1997)
Literature Review
• Work Environment Factors
• This factor deals mainly with the workplace
environment, includes such as staffing structures and
levels, availability and environment condition(Karsh,
Holden, &Alper, Or, 2011).
• Besides, the team's environment is partly controlled
by senior clinicians and managers. Equipment is also
an important area of concern for patient safety
(Buckle et al, 2006, Thomas & Galvin, 2008).
Literature Review
• Organizational and Management Factors
• There are many organizational and managerial factors that can
influence all workers’ behavior (Landy & Conte, 2008)
• These factors include: safety culture, manager’s leadership,
and workplace communication procedures (Flin, Winter,
Sarac, & Raduma, 2009).
• The healthcare organization, in turn, is also affected by
financial constraints (Valente, & Stanhope, 1988).
Literature Review
• Work Group/ Team Factors
• Good teamwork can help to reduce patient safety problems
(Bower, Campbell, Bojke, & Sibbald, 2003).
• The factors that influence team performance include the group
structure, group processes or dynamics and by the team leader
or supervisors’ actions (Valente, & Stanhope, 1988; Flin,
Winter, Sarac, & Raduma, 2009).
• The way individuals practice are also constrained and
influenced by the way the team members communicate with,
support, and supervise each other (Valente, & Stanhope, 1988).
Literature Review
• Task factors
• For each task, it is important that the nurse be sure
that she/he is dealing with the right patient (BeuscartZéphira, Pelayoa, Bernonville, 2010).
• These are characteristics of the tasks or jobs,
including what the tasks themselves are, as well as
characteristics such as time pressure, job control, and
workload (Karsh, et. al., 2011).
• For example, if not having sufficient time may cause
some of the workload-related problems (Carayon,
Gurses, 2005).
Literature Review
• Individual Factors (staff and Patient)
• At the individual level, there are many different
psychological and physiological factors which can
influence workers’ behaviors that contribute to safety
outcomes (Flin, Winter, Sarac, & Raduma, 2009).
• The human factors addressed at this level, such as the
patient's personality, may influence communication
with staff.
• A number of staff factors, such as personality,
experience, training and managing personal resources
(stress and fatigue), may be influential (Valente, &
Stanhope, 1988; Flin, Winter, Sarac, & Raduma,
2009).
Literature Review
• According to literature review, the focus of this
research is on five main categories of factors,
including: Environment Factors,
Organizational and management factors,
Team factors, Task factors and Individual
(staff and Patient) factors.
A
Patient & HCP (Human Capital
Planner)factors
ˇ
Task / Job factors
ˇ
Technology & tool factors
ˇ
Environmental factors
ˇ
Organizational factors
ˇ
External environment factors
ˇ
B
D
E
F
G
ˇ
ˇ
ˇ
ˇ
ˇ
ˇ
ˇ
Liveware factors
ˇ
Software factors
ˇ
Hardware factors
ˇ
Team /Crew factors
C
ˇ
ˇ
ˇ
ˇ
ˇ
ˇ
ˇ
ˇ
Communication
ˇ
ˇ
ˇ
ˇ
ˇ
Cognition & mental workload
ˇ
Service / product design
ˇ
Process design
ˇ
Note: A: Input-transformation-output modrl (Karsh,Holden,Alper,Or,2011)
B: SHEL model (Molloy,& O’Boyle, , 2005)
C: TheUniversity of Texas Threat&Error Model(Helmreich &Musson, 2000)
D: WHO patient Safety Report(Flin,Winter,Sarac,&Raduma,2009)
E: Team Training Program(Marshall&Manus,2007)
F: Carthey,&Clarke,(2009)
G: Valente, Taylor-Adams & Stanhope (1988)
ˇ
ˇ
Methodology
• Factor Analysis
This study will choose Exploratory Factor Analysis (EFA) to
test those underlying factors that are present in the scale
• Fuzzy AHP
This paper proposes the use of fuzzy AHP method to determine
the factors of patient safety assessment systems. The AHP
addresses how to determine the relative importance of a set of
activities in a multi-criteria decision problem(Saaty, 1980).
Expected results
• This study does offer initial information
about the factor structure of a validated
assessment scale for patient safety.
• Identifying and ranking the important of
factors of patient safety by expert consultation.
• Provide an insight for the senior clinicians and
managers to confirm the factors that enhance
safety for patients in health care.
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