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Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
1
Importance of Human Factors inQuality Improvement
Jennie J. Gallimore, Ph.D.
Dept. of Biomedical, Industrial,
and Human Factors Engineering
Wright State University
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
2
Error
You’ve carefully thought out all the angles.
You’ve done it a thousand times.
It comes naturally to you.
You know what you’re doing, its what you’vebeen trained to do your whole life.
Nothing could possibly go wrong, right ?
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
3
Think Again.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
4
Outline
Human Factors Defined
What Do Human Factors Engineers do?
Human Error Analysis: One Example Technique
How should you get started?
Document System Changes
Conclusion
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
5
Human Factors Defined
Human Factors discovers and applies information abouthuman behavior, abilities, limitations, and othercharacteristics to the design of tools, machines, systems,tasks, jobs, and environments for productive, safe,comfortable, and effective human use (Sanders andMcCormick, 1993)
Human Factors IS NOT …just applying checklists and guidelines
just using oneself as the model for designing things
just common sense
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
6
Cost of Ignoring Human Factors IsPoor Quality!
Increased probability of accidents and errors
Less spare capacity to deal with emergencies
Increased labor turnover
Lower productive output
Increases in lost time
Higher medical costs
Higher material costs
Increased absenteeism
Low quality work
Injuries, strains
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
7
What Do HFEs Do?
Human Factors Engineering uses a systems analysisapproach.
Humans are considered a critical system component.
HFEs analyze systems focusing on human operators todetermine what they are required to do to achieve systemgoals.
HFEs determine how the system can be designed ormodified to meet goals.
Humans have certain capabilities and limitations, and thesystem must be designed with an understanding of thehuman component subsystem requirements.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
8
What Do HFEs Do?
PerformSystemsAnalysis
System DesignModifications,Performancesupport, Aids
Integrate Solutions
Perform Scientific Research
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
9
What Do HFEs Do?
� Function analysis� Task Analysis (cognitive, physical)� Accident/incident analysis� Workload analysis� Communication patterns/information flow� Work place layout� Environmental Analysis� Task-Interface analysis� Reliability assessment (Human error analysis)� Etc.
PerformSystemsAnalysis
System DesignModifications,Performancesupport, Aids
Integrate Solutions
Perform Scientific Research
System Analysis
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
10
What Do HFEs Do?
PerformSystemsAnalysis
System DesignModifications,Performancesupport, Aids
Integrate Solutions
Perform Scientific Research
System Analysis
Systems Analysis Tools/Techniques
� Activity sampling� Hierarchical task analysis� Link analysis� Simulation studies� Verbal protocols� Interviews� Questionnaires
� Critical Incident Techniques� Decision action trees� Decision ladders� Operator action event trees� Time line analysis� Time and motion study� Etc.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
11
What Do HFEs Do?
PerformSystemsAnalysis
System DesignModifications,Performancesupport
Integrate Solutions
Perform Scientific Research
System Modifications
� Redesign of workflow (task sequence, responsibility)� Environmental improvements (noise, lighting, alarms)� Redesign of information flow� Development of support technology� Changes to system interfaces� Suggest changes to organizational policies� Develop training programs� Incorporation of safety systems
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
12
What Do HFEs Do?
PerformSystemsAnalysis
System DesignModifications,Performancesupport, Aids
Integrate Solutions
Perform Scientific Research
Integration of Solutions
� Organizational changes and support� Training� New Technology� Cost-benefit analysis
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
13
What Do HFEs Do?
PerformSystemsAnalysis
System DesignModifications,Performancesupport, Aids
Integrate Solutions
Perform Scientific Research
Human Factors Research
� R&D of system and task analysistechniques� Human decision making� Cognitive modeling� Mental workload� Visual performance� Shift work� Simulation and modeling� Display of information
� Effects of aging on performance� Adaptive displays� Communication� Test and Evaluation� Usability Testing� Human computer interaction� Safety� Training� Biomechanics
� Physical workload� Manual material handling� Human Error� Virtual Environments� Complex system modeling� Human control and tracking� Auditory perception� Multi-modal interfaces� Individual differences
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
14
Human Error Analysis:One Example of a Human Factors
Analysis Technique
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
15
Human Error and Accidents
• “Human beings by their very naturemake mistakes; therefore, it isunreasonable to expect error-freehuman performance.”
• Shappell & Wiegmann, 1997
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
16
Human Error and Accidents
� It is not surprising then, that human error hasbeen implicated in 60-80% of accidents incomplex systems.
� In fact, while accidents solely attributable toenvironmental and mechanical factors have beengreatly reduced over the last several years, thoseattributable to human error continue to plagueorganizations.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
17
Org
aniz
atio
nal F
acto
rsUnsafe
Supervisio
n
Preconditions
Unsafe Acts
Where Do We Usually Lookto Prevent Accidents?
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
18
Human Error and Accidents
Why is the human blamed?It is human nature to blame what appears to be theactive operator when something goes wrong.Our legal system is geared toward the determination ofresponsibility, fault, and blame.It is easier for management to blame the worker than toaccept the fact that the workplace, procedure,environment, or system needs improving.The forms we fill out to investigate accidents areusually modeled after the unsafe act, unsafe conditiondichotomy.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
19
Org
aniz
atio
nal F
ailu
res
Unsafe Superv
ision
Preconditions
Unsafe Acts
Where Should We Lookto Prevent Accidents?
OperatingEnvironment
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
20
Human Factors Analysis andClassification System (HFACS)
HFACS is based on the “Swiss Cheese” model oferror by James Reason (1990)
Applied to human error analysis in aviation byScott Shapell, Ph.D., Civil Aeromedical Institute and
Doug Wiegmann, Ph.D., University of Illinois
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
21
HFACS: Guiding Principles
Principle 1: Health care systems are similar in nature to other complex productive systems.Principle 2: Human errors are inevitable within such a system.Principle 3: Blaming errors on the human is like blaming a mechanical failure on the device.Principle 4: An accident, no matter how minor, is
a failure of the system.Principle 5: Accident investigation and error prevention go hand-in-hand.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
22
Latent Conditions� Excessive cost cutting
� Inadequate promotion policies
Latent Conditions� Deficient training program
� Improper crew pairing
Active and Latent Conditions� Poor team work/team resource management
� Loss of situational awareness
Failed orAbsent Defenses
OrganizationalFactors
Inputs�Economic
inflation
�Few qualifiedprofessionals
�Regulations
�Governmentpolicies
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Adapted from Reason (1990)
Accident/Injury
Active Conditions� Incorrect calculation of dosage
� Incorrect use of equipment
� Did not communicate all neededinformation
�Did not check device
Breakdown of a Productive System
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
23
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
DecisionErrors
DECISION ERROR� Rule-based Decisions - If X, then do Y - Highly Procedural� Choice Decisions - Knowledge-based � Ill-Structured Decisions - Problem solving
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
24
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
Skill-BasedErrors
SKILL-BASEDERRORS
� Attention Failures - Breakdown in information scan - Inadvertent operation of control� Memory Failure - Omitted item in checklist - Omitted step in procedure - Forgot to check device
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
25
DecisionErrors
Violations
ExceptionalRoutine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
Skill-BasedErrors
UNSAFEACTS
UNSAFEACTS
PerceptualErrors
ErrorsErrors
PERCEPTUALERRORS
� Misread label� Misread chart� Misjudge type of auditory alarm
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
26
DecisionErrors
Exceptional
Violations
Routine
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
Skill-BasedErrors
UNSAFEACTS
UNSAFEACTS
Violations
Routine
ROUTINE (INFRACTIONS)(Habitual departures from rules condoned by management)
� Violation of Orders/Regulations/Standard Operating Procedures -not checking ID bands -failure to confirm allergy status when ordering antibiotic in doctors office -Double check system for blood transfusion -Side bed rails not raised
�Failed to Adhere to policy� Not Current/Qualified for procedure� Improper Procedures
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
27
Routine
Violations
Exceptional
UNSAFEACTS
UNSAFEACTS
ErrorsErrors
PerceptualErrors
DecisionErrors
Skill-BasedErrors
Exceptional
UNSAFEACTS
UNSAFEACTS
Violations
Exceptional
EXCEPTIONAL(Isolated departures from the rules not condoned
by management)
� Violated - Keep drugs on floor- Extending surgical procedure without patient consent
�Accepted Unnecessary Hazard� Not Current/Qualified for Procedure� Violated standard medical practice
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
28
PersonalReadiness
Crew ResourceMismanagement
AdversePhysiological
States
Physical/Mental
Limitations
AdverseMentalStates
SubstandardConditions of
Operators
SubstandardConditions of
Operators
SubstandardPractices ofOperators
SubstandardPractices ofOperators
PRECONDITIONSFOR
UNSAFE ACTS
PRECONDITIONSFOR
UNSAFE ACTS
SubstandardConditions of
Operators
SubstandardConditions of
Operators
AdverseMentalStates
ADVERSE MENTAL STATE
� Loss of Situational Awareness� Circadian dysrhythmia� Alertness (Drowsiness)� Overconfidence� Complacency� Task Fixation
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
29
PRECONDITIONSFOR
UNSAFE ACTS
SubstandardConditions of
Operators
SubstandardConditions of
Operators
SubstandardPractices ofOperators
SubstandardPractices ofOperators
PersonalReadiness
Crew ResourceMismanagement
AdversePhysiological
States
Physical/Mental
Limitations
AdverseMentalStates
PRECONDITIONSFOR
UNSAFE ACTS
SubstandardConditions of
Operators
SubstandardConditions of
Operators
AdversePhysiological
States
ADVERSE PHYSIOLOGICALSTATES
� Medical Illness� Extreme fatigue
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
30
SubstandardConditions of
Operators
SubstandardConditions of
Operators
SubstandardPractices ofOperators
SubstandardPractices ofOperators
PRECONDITIONSFOR
UNSAFE ACTS
PersonalReadiness
Crew ResourceMismanagement
AdversePhysiological
States
Physical/Mental
Limitations
AdverseMentalStates
PRECONDITIONSFOR
UNSAFE ACTS
SubstandardConditions of
Operators
SubstandardConditions of
Operators
Physical/Mental
Limitations
PHYSICAL/MENTALLIMITATIONS
� Lack of Sensory Input� Limited Reaction Time� Incompatible Physical Capabilities� Incompatible Intelligence/Aptitude
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
31
CREW RESOURCEMISMANAGEMENT
PRECONDITIONSFOR
UNSAFE ACTS
Crew ResourceMismanagement
SubstandardPractices ofOperators
SubstandardPractices ofOperators
PRECONDITIONSFOR
UNSAFE ACTS
PersonalReadiness
AdversePhysiological
States
Physical/Mental
Limitations
AdverseMentalStates
SubstandardConditions of
Operators
SubstandardConditions of
Operators
SubstandardPractices ofOperators
SubstandardPractices ofOperators
Crew ResourceMismanagement
� Not Working as a Team� Poor team Coordination� Improper Briefing Before a Procedure� Inadequate Coordination ofmaterials/technologies/human resources
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
32
PRECONDITIONSFOR
UNSAFE ACTS
SubstandardConditions of
Operators
SubstandardConditions of
Operators
SubstandardPractices ofOperators
SubstandardPractices ofOperators
PersonalReadiness
Crew ResourceMismanagement
AdversePhysiological
States
Physical/Mental
Limitations
AdverseMentalStates
PRECONDITIONSFOR
UNSAFE ACTS
SubstandardPractices ofOperators
SubstandardPractices ofOperators
PersonalReadiness
PERSONAL READINESS
Readiness Violations� Rest Requirements� Self-Medicating
Poor Judgement� Poor Dietary Practices� Overexertion While Off Duty
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
33
UNSAFESUPERVISION
UNSAFESUPERVISION
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
InadequateSupervision
INADEQUATE SUPERVISION
� Failure to Administer Proper Training� Lack of Professional Guidance
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
34
UNSAFESUPERVISION
UNSAFESUPERVISION
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
PlannedInappropriate
Operations
INAPPROPRIATEPRACTICES
� Risk without Benefit� Improper Work Tempo� Poor Team Pairing
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
35
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UNSAFESUPERVISION
UNSAFESUPERVISION
Failed toCorrectProblem
FAILED TO CORRECT AKNOWN PROBLEM
� Failure to Correct Inappropriate Behavior� Failure to Correct a Safety Hazard
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
36
InadequateSupervision
PlannedInappropriate
Operations
Failed toCorrectProblem
SupervisoryViolations
UNSAFESUPERVISION
UNSAFESUPERVISION
UNSAFESUPERVISION
UNSAFESUPERVISION
SupervisoryViolations
SUPERVISORY VIOLATIONS
� Not Adhering to Rules and Regulations� Willful Disregard for Authority by Supervisors
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
37
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ResourceManagement
ResourceManagement
ORGANIZATIONALINFLUENCES
RESOURCE MANAGEMENT� Human� Monetary� Equipment/Facility
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
38
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ORGANIZATIONALINFLUENCES
OrganizationalClimate
ORGANIZATIONALCLIMATE� Structure� Policies� Culture
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
39
OrganizationalClimate
ResourceManagement
ResourceManagement
OperationalProcess
ORGANIZATIONALINFLUENCES
ORGANIZATIONALINFLUENCES
OperationalProcess
OPERATIONALPROCESS� Operations� Procedures� Oversight
OrganizationalInfluences
UnsafeSupervision
Preconditionsfor
Unsafe Acts
UnsafeActs
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
40
FAR Part 91 - General Aviation:Fatal vs. Non-Fatal Accident Comparison
0
10
20
30
40
50
60
70
80
90
100
90 91 92 93 94 95 96 97 98
0
10
20
30
40
50
60
70
80
90
100
90 91 92 93 94 95 96 97 980
10
20
30
40
50
60
70
80
90
100
90 91 92 93 94 95 96 97 98
Year
0
10
20
30
40
50
60
70
80
90
100
90 91 92 93 94 95 96 97 98
Perceptual Errors Violations
Decision ErrorsSkill-based ErrorsP
erce
ntag
e of
Acc
iden
tsP
erce
ntag
e of
Acc
iden
ts
Per
cent
age
of A
ccid
ents
Per
cent
age
of A
ccid
ents
Percentages do not add up to 100% Percentages do not add up to 100%
Percentages do not add up to 100% Percentages do not add up to 100%
Fatal
Non-Fatal
* Incomplete
FatalNon-Fatal
* Incomplete
Fatal
Non-Fatal
* Incomplete
Year
Year Year
Fatal
Non-Fatal
* Incomplete
Year
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
41
Feedback
HumanError
- Errors occurfrequently and arethe major cause ofaccidents.
- Few safety programsare effective atpreventing theoccurrence orconsequences ofthese errors.
Research Sponsors
- AHRQ, NPSF, Health systempartners, VA, NIH
- Lack of adequate funding forsafety research in healthsystems.
- Lack of good data leads toresearch programs basedprimarily on interests andintuitions. Interventions aretherefore less effective.
Fad-DrivenResearch
Mit
igat
ionP
reve
ntio
nIneffectiveIntervention
and PreventionPrograms
AccidentInvestigation
- Lack of sophisticatedtechniques andprocedures
- Information isqualitative andillusive
- Focus on “what”happened but not“why” it happened
AccidentDatabase
- No real accidentdatabase
- Not designedaround anyparticular humanerror framework
- Variables often ill-defined
- Organization andstructure difficultto understand
Wiegmann, D. & Shappell, S. (In press). Human error analysis of commercial aviation accidents: Application of the Human FactorsAnalysis and Classification System (HFACS). Aviation, Space, and Environmental Medicine.
DatabaseAnalysis
- Few analyses havebeen performedto identifyunderlyinghuman factorssafety issues.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
42
DatabaseAnalysis
- Few analyses havebeen performedto identifyunderlyinghuman factorssafety issues.
HumanError
- Errors occurfrequently and arethe major cause ofaccidents.
- Few safety programsare effective atpreventing theoccurrence orconsequences ofthese errors.
Fad-DrivenResearch
Mit
igat
ionP
reve
ntio
nIneffectiveIntervention
and PreventionPrograms
AccidentInvestigation
- Less sophisticatedtechniques andprocedures
- Information isqualitative andillusive
- Focus on “what”happened but not“why” it happened
AccidentDatabase
- Not designedaround anyparticular humanerror framework
- Variables often ill-defined
- Organization andstructure difficultto understand
HFACSHFACS
AccidentInvestigation
- Sophisticatedtechniques andprocedures
- Information isqualitative andquantitative
- Focus on both“what” happenedand “why”
AccidentDatabase
- Designed around awell-known humanerror framework
- Well-definedvariables
- Organization andstructure easy tounderstand
HumanError
- Errors occur lessfrequently.
- Safety programs areeffective atpreventing theoccurrence orconsequences ofthese errors.
Fad-DrivenResearch
Data-DrivenResearch
EffectiveIntervention
and PreventionPrograms
DatabaseAnalysis
Analyses can nowbe performed toidentify humanfactors safetyissues
- Traditionalhuman factorsanalyses are lessdifficult due towell-definedvariables anderror database
-
Research Sponsors
- NIH, ARHQ, NPSF, Healthsystem partners
- Lack of adequate funding forsafety research in healthsystems.
- Lack of good data leads toresearch programs basedprimarily on interests andintuitions. Interventions aretherefore less effective.
Research Sponsors
- AHRQ, NPSF, Health systempartners, VA, NIH
- Research programs are needs-based and data-driven.Interventions are thereforevery effective.
Feedback
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
43
Human Factors Has Been Effectively Appliedto a Variety of Complex Systems
AviationDesign of aircraftAir Traffic control
Nuclear Power PlantsManufacturingAerospace
Space stationSpace shuttles
AnesthesiologyComputer SystemsRemotely Operated VehiclesAutomobiles
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
44
How Should We Start?
Get a degree in human factors in your spare time!
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
45
How Should We Start?
Get a degree in human factors in your spare time!
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
46
How Should We Start?
Work with a human factors consultant specialistUse your purchasing clout to work with vendorsBe sure to document benefits from systemmodifications
It is important to determine how analysis andintervention have affected the system. Cost-benefitanalysis is an important aspect of the systemsengineering approach.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
47
Example System Benefits
Reduction in reportedincidents and accidentsReduction in errorImproved communicationReduced personnelrequirements becausetasks can be more easilyaccomplishedIncreased customersatisfactionMore quality time withcustomers
Reduced job injuries
Reduced patient waitingtimes
Less “lost” information(forms, documents, etc)
Better handoff
Reduced workload
Increased worker jobsatisfaction
Etc…
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
48
Conclusion
The profession of Human Factors is dedicated toimproving the quality of complex systems.Lessons learned can be directly applied to medicalsystems. Work with Human Factors Engineers tobenefit from their expertise.
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
49
Acknowledgements
Thanks to Scott Shapell, Ph.D., from the CivilAeromedical Institute and Doug Wiegmann,Ph.D., from the University of Illinois forpermission to use and edit slides from theirpresentation “A Human Factors Approach toAccident Analysis and Prevention.”
Jennie J. Gallimore,Ph.D.,Dept. of Biomedical, Industrial, & Human Factors Engineering
50
Suggested Reading
Introductory Textbooks on Human FactorsSanders, M.S. and McCormick, E.J. (1993) Human Factors inEngineering and Design, 7th Ed. New York: McGraw Hill, Inc.
Wickens, C.D., Gordon, S. E, and Liu, Y. (1998) An Introductionto Human Factors Engineering. New York: Addison-WesleyEducational Publishers, Inc.
Bogner, M. S. (Ed.) (1994). Human error in medicine.Hillsdale, NJ: Lawrence Erlbaum Associates.
Reason, J. (1990). Human error. Cambridge, England:Cambridge University