However, the environment (i.e., the conditions under which humans work) can be modified by building mechanisms into Human Factors: A New Look at Error The IOM report drew heavily from the field of human factors. Also called human factors research, or human factors engineering, it is a multidisciplinary field that draws upon diverse disciplines—psychology, engineering, industrial design, statistics, and operations research—to understand the interactions among people, technology, and work environments and enhance human performance in the workplace. In other words, how do people interact with technology and process systems, but most importantly, how can these interactions be studied, improved upon, and understood to reduce adverse events for patients? From a safety perspective, the field examines work processes, equipment, and devices, and then redesigns them to accommodate the physical and cognitive limitations of human beings. The human factors approach does not excuse individual incompetence or negligence. This approach attributes harm to insufficient layers of protection embedded in work processes, emphasizing distraction, communication failures, and fatigue as major contributors to individual mistakes According to Oster and Braaten (2021), the science of human factors considers a variety of factors, such as: ● Components of human–system interfaces ● Working environments: Organizational, social, and physical ● The precise nature of the work being done ● Individual characteristics, including performance factors Questions such as how the human factor influences the critical work done in healthcare are central to human factors thinking. For example, how do providers and frontline staff perform multiple tasks simultaneously without sacrificing accuracy and skill? This question is critical, given the automatic mental patterns that can govern the actions of staff who all too regularly perform similar tasks over and over again. These professional habits can be quite effective, though they may need to be analyzed if they create conditions for error. The science of human factors attempts to circumvent habits and cognition that can create risky situations. One approach is a mindset of anticipation. The conscious adaptation of anticipating harm or mistakes Slips, Lapses, and Mistakes James Reason, a psychologist and leading human factors researcher, has studied how people perform in complex environments and has identified three common errors in the workplace (Reason, 1990): Slips, lapses, and mistakes. Slips are errors that tend to occur during automatic, skill-based activities (Reason, 2005). Some examples are inadvertently squeezing ointment instead of toothpaste onto a toothbrush because the two tubes look alike, taking the wrong exit off the highway, or going to answer the door when the telephone rings. Distraction—whether an external stimulus in the environment (such as noise or interruption) or an internal stimulus (such as nagging worry, focused concentration on an upcoming task or event, or a physiological state such as fatigue)—creates the perfect environmental conditions for a slip (Reason, 2005). A lapse is related to cognition rather than an activity and is therefore not visible (Reason, 2005). Memory failure is an example of a lapse. Lapses tend to occur during rule-based activities such as following a diagnostic guideline or a treatment protocol, and most lapses are not conscious; a step is simply forgotten. But sometimes, under certain conditions, a worker will commit a lapse knowingly. This is most likely to happen when a guideline or protocol seems too difficult,
the system to prevent harm or lessen the effects of human error.
is fundamentally different than the organizational pattern of simply reacting to error (Oster & Braaten, 2021). Another key concept derived from human factors is the active development of a new organizational mindset— identifying system failures versus merely identifying human failures. Of course, people are responsible for their actions within a healthcare setting; however, the system, or lack thereof, is also a considerable determining factor in adverse patient events. Gravitating to a systems perspective is essential because healthcare in general, and nursing in particular, are operations that are perpetually exposed to frequent interruptions of all kinds. This can create risk for patients, and a systems approach would seek to ameliorate this facet of the system. For example, according to Oster and Braaten (2021), nurses are interrupted approximately 12 times each working hour, and many of these interruptions occur at critical moments that can affect patient safety, such as during the medication administration. Oster and Braaten outline several concrete examples of how human factor thinking can be implemented. Physical Human Factors ● Modify the environment to reduce perception time, decision time, and manipulation time ● Design the environment to reduce or mitigate the need for excessive physical exertion ● Design workstations for ideal or desired physical movement Cognitive Human Factors ● Match technology with the user’s expectations and mental models ● Minimize cognitive load on staff ● Allow for error detection, recovery, and processing ● Provide timely and in-depth feedback to staff Organizational Human Factors ● Provide opportunities for staff to learn and develop new skills ● Allow staff input and control over work systems ● Support staff with access to social support ● Involve staff in system design, innovation, and evaluation its rationale is not understood, or time constraints make it tempting to skip a step to get the job done (Reason, 2005). A mistake is more complex than a slip or a lapse. It is a deficit or failure in judgment that occurs when specialized knowledge is required, such as when selecting a treatment goal or formulating a treatment plan (Reason, 2005). Mistakes are most likely to occur when a process is complex or when a situation is new or unfamiliar. Some mistakes, such as diagnostic judgments, may go unnoticed for a long time, and when detected, they sometimes remain a matter of debate. For example, the selection of a particular treatment plan or the decision to discharge a client from an inpatient setting is open to a range of opinions. Addressing Slips, Lapses, and Mistakes: Forcing and Constraining Concepts Human factors experts have devised strategies to compensate for slips, lapses, and mistakes. According to Reason (1990), among the basic strategies used in healthcare are redundancy functions, forcing functions, and constraining functions. Of these strategies, redundancy functions are the easiest to apply to behavioral health. A redundancy function is a checking function that builds backups or double-checks into a work process.
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