ILS - Workshop February 2015

Safety Barriers

Luis E. Fong de los Santos, Ph.D.

February 2015ILS - Workshop

Learning Objectives

• Review the definition of Safety Barrier according to ILS consensus recommendations white paper.

• Review the concept of Human Tasks vs Error Type.• Review the concept of Safety by Design.• Review Mistake Proofing Tools and the Hierarchy

of Safety Interventions.

February 2015ILS - Workshop

Safety Barriers

February 2015ILS - Workshop

Safety BarriersExternal Beam Brachytherapy

February 2015ILS - Workshop

Safety BarriersSafety Barrier (SB): Any process step whose primary function is to prevent an error or mistake from occurring or propagating through the radiotherapy workflow

February 2015ILS - Workshop

Safety Barriers

Out 91 steps -> 35 SB Out 88 steps -> 32 SB

External Beam Brachytherapy

February 2015ILS - Workshop

Human Tasks and Error Type

• Tasks requiring schematic behavior, in other words done “on autopilot”– Error Type: Slips or Omissions. They are associated with

lapses of concentration, distractions, exhaustion or burnout

• Tasks requiring attentional behavior, which need a predefined active plan and problem-solving skills– Error Type: Mistakes. Often occurring due to lack of

experience, poor training, poor judgment or misunderstanding a situation

February 2015ILS - Workshop

Safety by Design

• Actions that prevent errors from happening.

• Actions that make errors quickly and easily

detectable when they occur.

• Actions that mitigate impact or fail safely.

• Grout, J.R. (2006). “Mistake proofing: Changing designs to reduce error.” Qual Saf Health Care 15(SUPPL. 1):i44–i49• Grout JR. Mistake-Proofing the Design of Health Care Processes. May 2007. Agency for Healthcare Research and Quality, Rockville, MD.

• http://archive.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/mistakeproof/index.html

February 2015ILS - Workshop

Human Factors Engineering (HFE)

HFE uses knowledge about human characteristics, both capabilities and limitations that are relevant during any designing process and aims to optimize the interactions among:• people, • machines, • procedures, • systems,• environments.

“We cannot change the human condition, but we can change the conditions under which humans

work.”- James Reason

February 2015ILS - Workshop

HFE - Poor vs Good Design

Norman, D. A. (2013). Design of Everyday Things: Revised and Expanded. New York: Basic Books. London: MIT Press

February 2015ILS - Workshop

HFE - Poor vs Good Design

Norman, D. A. (2013). Design of Everyday Things: Revised and Expanded. New York: Basic Books. London: MIT Press

February 2015ILS - Workshop

PRE‐INCISION

CHECK BOOLD PRESS‐‐URE

ALLERGIES?CHECK PULSECHECK MEDICATION 

USE (IF YES, SEE CHECKLIST PAGE c‐112)VERIFY SITE,

IDENTITY,PROCEDURE,CONSENT

Patient has confirmed:‒ Site‒ Identity‒ Procedure‒ Consent

Site marked or not applicable

Allergies Yes (list) No

Pulse oximeter in place and working

All items must be verbally verified by patient and nurse

BEFORE INCISION

Poor Improved

Poor Designed:a) Use of “pre” may look similar to “post”. Before and After are 

less likely to be confusedb) Vague question; unknown what a check here would meanc) Boxes are low contrast. Far removed from the action they refer 

tod) Lack of whitespace & use of caps decreases readabilitye) Listed actions not clearly separatedf) Creates undue load on memory, both in keeping the current 

checklist in mind while looking at another page and in the lengthy wording: “CHECKLIST PAGE c‐112”

(a)

(b)

(c)

(d)

(e)(f)

(a)

(b)

(a)

(c)

(d)

Improved Designed:Overall flow moves from questions that need patient input and confirmation to actions that need to be confirmed by nursing team. Whitespaces and changes in font act as visual cues for flow through the checklist and completeness.a) High contrast textb) Responsibility assignedc) Outcome of allergy questioning is clear; environmental 

support added by having allergens recordedd) Raised boxes draw attention and shadow gives additional 

contrast

McLaughlin, A. C. (2010). What Makes a Good Checklist. In, (AHRQ) - http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=92

February 2015ILS - Workshop

Safety Interventions

Training and Education

Policies and Procedures

Reminders and Checklists

Simplification and Standardization

Automation and Computerization

Forcing Functions and Constraints

Institute for Safe Medical Practices, Vaida et al. 1999

February 2015ILS - Workshop

Hazard Mitigation Effectiveness

o Forcing Functions and Constraints

o Automation and Computerization

o Simplification and Standardization

o Reminders and Checklists

o Policies and Procedures

o Training and Education

Institute for Safe Medical Practices, Vaida et al. 1999

Haz

ard

Miti

gatio

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ffect

iven

ess

Leas

t Effe

ctiv

eM

ost E

ffect

ive

Human Factor

February 2015ILS - Workshop

Attributes of Good Mistake Proofing

• Effective in preventing errors or harm• Inexpensive• Require minimal training and minimize

implementation resistance

FMEA & RPNRisk Priority Number:

Occurrence x Detectability x Harm

* Godfrey AB, Clapp TG, Nakajo T, et al. Application of healthcare-focused error proofing: principles and solution directions for reducing human errors. Seattle: Proceedings of the ASQ World Conference on Quality and Improvement, 16–18 May, 2005.

*SPNSolution Priority Number:

Effectiveness x Cost x Ease of implementation

Note: The best designs will not be cumbersome or slow the process down. Rather, design changes that reduce errors and speed up processes go

together.

February 2015ILS - Workshop

Summary

SafetyBarriers

Effective

Inexpensive Easy to Implement

Human Factors Environment

FlexibleOptimize

processes