XVIII NATIONAL SEMINAR ON HOSPITAL &HEALTHCARE
MANAGEMENT
MEDICOLEGAL SYSTEM &CLINICAL RESEARCH
Symbiosis Institute of Health science
Improving healthcare outcomes
by
managing human factors
Dr Uttam Shiralkar
M.S.FRCS , MRCPsych,
Fellow in cancer surgery, USA
overview
• Why do we need it, why me, why you
• Why now
• What is it
• How it works
• How to train and get trained
Why me?
Improving the relationship between an individual &
work environment by focusing on efficiency,
creativity, productivity and job satisfaction
Institute of Medicine (USA)
report
‘To err is human’
Every year, 20,000 patients
die after an elective surgery
in the USA
 Worldwide 234 million
surgical procedures are done
each year
Medicine Vs Aviation
• Chances of serious injury in
air travel are 1 in 36000
years
• Its not that bad
doctors/nurses make
mistakes – anybody can
• Need to think why does it
happen
Critical events in operating room among 1,440,776
patients for elective surgery,
Japanese JOA, 2005
Four subgroups
Anaesthetic management (AM)
Intra- operative pathological event (IP)
Surgical management (SM)
Preoperative complication (PC)
IP events responsible for 37% cardiac arrests
SM responsible for 35% CA & 27% other CE
SM, IP responsible for 67% & 22% deaths
Human factors ( SM & AM) responsible for 54% CA, 74% other
CE and 71% deaths
The role of technology
• Technology shifts the
workload
• Automation makes systems
more ‘opaque’
• Contributes to system
complexity
• Over reliance on the
accuracy
• Plays role in errors
Organizational barriers
Inconsistency in team membership
Lack of information sharing
Complacency
Conflict
Lack of co-ordination and follow-up with co-workers
Distractions
Workload
Misinterpretation of data
Lack of role clarity
Strategies to overcome barriers
• Brief
• Debrief
• Huddle
• Cross monitoring
• Feedback
• Advocacy
• Two challenge rule
Complex system - stakeholders
Government
& society
Drug
corporations
& insurance
companies
Hospitals
Patient
Health
professionals
& allied
workers
Human factor approaches
• Critical incident analysis
• Naturalistic decision making
• System analysis
• Root cause analysis
Critical incident analysis
• Loss of situational awareness – Due to the stress the consultants
involved became highly focussed on repeated attempts to insert the
breathing tube
• Perception and cognition - actions were not in line with the
emergency protocol.
• Teamwork – there was no clear leader.
• Culture – Nurses who sensed the urgency early on brought the
emergency kit to the room. The hierarchy of the team made
assertiveness ineffective
Naturalist decision making
Consultant- 1
oFirst consultation
oX ray - inconclusive
oSplint for 4 week- no relief
oMRI - Cysts in the scaphoid and lunate
oRe-splinting & steroid injections for one year
without any improvement
oDiagnosed as “hyperactive synovium” & advised
stripping of the synovium
Consultant- 2
oDismissed the diagnosis “hyperactive synovium”
oMRI - Three bone cysts & a hairline fracture in the
scaphoid & displaced tendons
oRecommended 3 separate procedures with 6
month interval in-between ; drain the cysts and bone
graft, pin the fracture and repositioning the tendons.
oRecovery period – 2 years
Consultant - 3
oMost renowned hand surgeon in the USA
oAdvised arthroscopy without detail examination
oDiagnosis?... “I will figure it out when I get there”
oProvisional diagnosis?... “ Chondro-calcinocis”
Consultant- 4
oFirst surgeon to examine and x-ray both hands
during manoeuvring
oDiagnosis – dynamic Scaphoid- Lunate instability;
partially torn ligament between scaphoid & lunate
with channels in the cyst causing inflammation
oRecommended bone grafting the cyst & ligament
repair
oSuccessful outcome
You have been given 10000 Rs
& have a choice of two options
A
• You will get additional 5000
Rs for sure
B
•A coin will be tossed
• ‘Heads’ get
additional 10000Rs
• ‘Tails’ get
nothing
You have been given 20000 Rs
& have a choice of two options
C
• You will have to return 5000
Rs for sure
D
•A coin will be tossed
• ‘Heads’ return
10000Rs
•‘Tails’ return
nothing
You are the chief of a medical unit which has
a responsibility to manage an outbreak of a
serious viral epidemic
If you choose plan A,
it could save 200
hundred people for sure.
If you choose plan B,
it could save all 600
people but only with a
1/3 probability.
If you choose plan A,
400 hundred people
could die for sure.
If you choose plan B,
all 600 people could die
with a 2/3 probability.
System analysis
Root cause analysis -medical error
• 5th leading cause of death
• Kills approx. 100000 people a
year in the USA alone
• Equal to 38 passenger planes
crashing every month
• 10% hospital patient
experience some sort of error
• 1% experience some kind of
harm
Types of medical errors
Active errors
Latent errors
• Occur at the level of the
frontier operator and their
effects are felt almost
immediately
• Tend to be removed from
the direct control of the
operator
• Poor design
• Faulty maintenance
• Bad management
decisions
• Poorly structured
organisations
Intensive care units
Vulnerable patients
• Multiple specialties
• Varied source of
information
• Many interventions at
same time
• 20% patients suffer adverse
event
• 45% of them were
preventable
• Diagnostic error,
medication error , hospital
infections
Transition of care
Medication errors and adverse drug
event
• 7.5% of hospital admission
• Heavy staff load & fatigue
• Inexperience
• Poor handwriting
• Poor lighting, noise,
interruptions
• Confusing nomenclature
• Frequency & complexity of
nomenclature
Human Factors training can assist
healthcare staff to:
• Understand why we make errors
• Understand how ‘systems factors’ can threaten patient
safety
• Improve the safety culture of teams and organisations
• Enhance teamwork and improve communication
• Improve the design of healthcare systems
• Identify ‘what went wrong’ and predict ‘what could go
wrong’
• Appreciate how human factors tools can be used to
reduce the likelihood of patient harm
Human factors training
• Oxford project – 30-50%
less technical error s after
the training
• Med Team project USA –
significant reduction in
A&E errors and improved
effeciency
• We expect medicine to be an orderly field of knowledge and procedures;
…...unfortunately…., it is not ! It is an imperfect science ; an enterprise of
constantly changing knowledge, uncertain information., fallible individuals and
at the same time, lives on line. There is a science in what we do, yes,
but also a habit.
The gap between what we know and what we aim for persists and
this gap complicates every thing we do. Medicine has become as high-tech
as it gets, but a health professional need to retain a deep recognition of
the limitations of both science and human skills…..
- Complications