View
0
Download
0
Category
Preview:
Citation preview
©2015 ECRI INSTITUTE
Human Factors Analysis 4 Health Care
Group Demonstration
October 15, 2015
©2015 ECRI INSTITUTE©2015 ECRI INSTITUTE
Directions
©2015 ECRI INSTITUTE3
HFACS4HC Taxonomy
Unsafe Acts
Errors Violations
Judgement and Decision-
making Errors
Skill-based Errors
Misperception errors
Routine (“Bending” the
rules)
Exceptional (Breaking the
rules)
CATEGORY
SUBCATEGORYSUBCATEGORY
NANOCODES
©2015 ECRI INSTITUTE4
Worksheet #1
HFACS4HC Taxonomy Worksheet■ Use this to determine
HFs.■ Use the checkboxes
©2015 ECRI INSTITUTE5
Worksheet #2
Review sections 1, 2, 3
Complete sections 4, 5, 6.
Use to report out your findings
©2015 ECRI INSTITUTE6
Worksheet #2
Review the following pre-filled sections■ 1. Event Description■ 2. Timeline■ 3. Interviews
Complete the following sections■ 4. HFACS4HC Findings■ 5. Summarize Nanocodes■ 6. Determine Action Plans
There are additional and optional sections. A template is included on the website.
©2015 ECRI INSTITUTE©2015 ECRI INSTITUTE
Sample Case Demonstration
©2015 ECRI INSTITUTE8
1. Event Description A 55-year-old man with a history of poorly controlled diabetes mellitus,
pancreatic insufficiency, and alcohol and cocaine abuse was found unconscious by his neighbors. The patient had last been seen 2 days prior and complained of dizziness, thirst, and nausea.
Emergency medical services found him unresponsive, with a Glasgow Coma Scale score of 3. He was intubated in the field.
Upon arrival in the emergency department (ED), his pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg, potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L. A right internal jugular line was placed for access. The resident who placed the line was relatively experienced in line placement but was unable to confirm placement with ultrasound. Instead he used manometry, which was not a part of the normal ED routine for line placement.
©2015 ECRI INSTITUTE9
1. Event Description (continued) He ultimately chose to pull the line. Just then, another trauma patient
arrived, and the supervising attending physician left the room. The resident opened a second line insertion kit and restarted the process. Ultrasound was used to confirm correct placement..
Upon flushing the line, it was noted that one of the ports was not working. The patient soon went into atrial tachycardia, which broke with adenosine. A chest radiograph was not obtained until later, after the patient went into ventricular fibrillation in the intensive care unit. When the chest radiograph was finally completed, a retained wire was noted in the pulmonary artery. The interventional radiology team was consulted for wire removal. The retained wire likely caused a cardiac arrest, which required shocks, chest compressions, and cooling. After guidewire removal, the patient had no further episodes of arrhythmias, but experienced several other serious complications during a prolonged and stormy hospitalization
©2015 ECRI INSTITUTE10
2. Timeline2.TimelineDate/Day/Time Event DescriptionPatient’s home Emergency crew intubates in the fieldER Arrives in ERER ER lab work pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg,
potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L.
ER Right internal jugular line was placedER Unable to confirm placement with ultrasound. Manometry used. Line removedER Supervising attending physician left the roomER The resident restarted the process. Ultrasound was used to confirm correct
placement. Upon flushing the line, it was noted that one of the ports was not working
ER Patient soon went into atrial tachycardia, which broke with adenosineICU Patient to intensive care. Experienced ventricular fibrillationICU Chest x-ray obtained and revealed a retained wire was in the pulmonary artery. Radiology The interventional radiology team was consulted for wire removal. The retained
wire likely caused a cardiac arrest, which required shocks, chest compressions, and cooling. After guidewire removal, the patient had no further episodes of arrhythmias, but experienced several other serious complications during a prolonged and stormy hospitalization
©2015 ECRI INSTITUTE11
3. Interviews
These usually have already been completed when the event was investigated. They will add to the facts.
You may want to add interviews based on findings.
3.Interviews
Date Title Name Notes
Attending Dr. Charge
Resident Dr. Joe
Other staff in room Nurse Mary
©2015 ECRI INSTITUTE12
Determine the HFACS4HC Nanocodes
Worksheet #1
Use this to determine HFs.
©2015 ECRI INSTITUTE13
4. HFACS4HC FindingsRecorder notes Nanocodes on Worksheet #2
4.HFACS4HC Findings: HFACS Category Sub Category Nano Codes Why? Unsafe Acts � Preconditions
for Unsafe Acts
� Supervision � Organization
al Influences
Error: skill based Error
Poor technique Did not use ultrasound to confirm placement of first jugular line
Unsafe Acts � Preconditions
for Unsafe Acts
� Supervision � Organization
al Influences
Judgment and Decision Making
Selected incorrect procedure Used manometry instead of ultrasound
Unsafe Acts � Preconditions
for Unsafe Acts
� Supervision � Organization
al Influences
Violation: Routine (Bending the Rules)
Violation of policy/procedure/standard of care Failed to make sure equip could be properly used Disabled guars, warning systems or safety devices
Used manometry instead of ultrasound
� Unsafe Acts Preconditions
for Unsafe Acts
� Supervision � Organization
al Influences
Environmental Factors: Technological Environment
inadequate/defective warnings/alarms
Use of manometry
� Unsafe Acts Preconditions
for Unsafe Acts
� Supervision � Organization
al Influences Unsafe Acts
Personnel Factors: Communication/Coordination/ Planning
Failed to use all available resources
Did not use ultrasound
©2015 ECRI INSTITUTE14
4. HFACS4HC Findings (continued)Recorder notes Nanocodes on Worksheet #2
� Unsafe Acts � Preconditions
for Unsafe Acts
Supervision � Organization
al Influences Unsafe Acts
Inadequate Supervision
Failed to provide adequate oversight Failed to identify at risk caregiver Failed to communicate policies Failed to provide adequate mentoring/coaching/instruction
Supervising attending present during first insertion yet does not require use of ultrasound
� Unsafe Acts � Preconditions
for Unsafe Acts
Supervision � Organization
al Influences Unsafe Acts
Failure to address Known Problem
Failed to report unsafe tendencies (allowing people to slide when they are wrong) Failed to initiate corrective action (correct known problem) Failed to ensure problem was corrected
Supervising attending leaves room despite knowing resident is planning to do a second insertion
� Unsafe Acts � Preconditions
for Unsafe Acts
Supervision � Organization
al Influences Unsafe Acts
Supervisory Violations
Failed to enforce policies/procedures/requirements Authorized hazardous operation: Allowing unknown hazardous operations to continue for whatever reason
Supervising attending allows use of manometry instead of ultrasound and leaves room despite knowing resident is planning to do a second insertion
� Unsafe Acts � Preconditions
for Unsafe Acts
� Supervision Organization
al Influences Unsafe Acts
Organizational Climate
Culture that does not condemn hazardous and/or unethical behavior
No member of team spoke up about lack of use of ultrasound
©2015 ECRI INSTITUTE15
5. Summary of NanocodesSum the nanocodes, subcategories, categories
©2015 ECRI INSTITUTE16
6. Actions - Create an Action Plan
©2015 ECRI INSTITUTE
Questions?
Thank You
©2015 ECRI INSTITUTE
Human Factors Analysis 4 Health Care
Break Out Work Groups
October 15, 2015
©2015 ECRI INSTITUTE19
PurposePractice applying HFACS4HC to a case
study.Develop a preliminary action plan.Discuss how you will use HFACS4HC in
your organization.
Remember, there are no wrong answers!
©2015 ECRI INSTITUTE20
Instructions
Assemble in your assigned group The ECRI Facilitator will lead you to your room Designate members of the group for the following roles:
■ A recorder■ A presenter■ A timekeeper
Use meeting time as follows:■ 15 minutes-review case study and timeline (Sections 1, 2, 3)■ 40 minutes-apply nanocodes and sum them into categories
(Sections 4 and 5)■ 20 minutes-develop actions for nanocodes (Section 6) and
discuss how you will use HFACS4HC in your organization
20
©2015 ECRI INSTITUTE21
Instructions Only apply HFACS4HC when the information is stated, do
not make assumptions Use index cards to record questions from the group to the
speakers panel. On return to the full meeting, report out:
■ Section 4. What HFs nanocodes did you identify? Why? ■ Section 5. Which Categories were your top 2? ■ Section 6. What actions did you plan? ■ Your thoughts/suggestions about how you will use HFACS4HC in
your organizations?
After the reports from the break out groups, the speakers panel will assemble for Q&A. Use index cards
21
©2015 ECRI INSTITUTE22
Worksheet #1
HFACS4HC Taxonomy Worksheet■ Use this to determine
HFs.■ Use the checkboxes
©2015 ECRI INSTITUTE23
Worksheet #2
Case Summary Complete sections
4, 5, 6. Use to report out
your findings
©2015 ECRI INSTITUTE24
Your breakout group color is indicated on your name badge
©2015 ECRI INSTITUTE25
Finish Breakout at 3:45 PMBreak 3:45 – 4:00 PMPlease return promptly at: 4:00 PM
©2015 ECRI INSTITUTE26
Please follow your ECRI facilitator to your classroom
Recommended