Understanding “Human Factors” is Not “Factors Associated with Being Human”
Modern healthcare relies on a variety of physical and digital assets and tools. Sophisticated medical devices help in diagnosing and treating disease. Advanced materials prevent the spread of bacteria. Diverse physical environments are used to deliver care and promote healing.
Even as the healthcare system relies on this tapestry of inanimate resources, healthcare remains fundamentally human. It’s people who give and receive care and people who help ensure safety and quality. Yet humans can also misstep. When humans make errors, we ask why.
Human factors engineers specialize in understanding how design of a system creates opportunities for human error. Their mission is to design work systems to support the work people need to accomplish. With that perspective, human error becomes an impetus to find weaknesses in the system so that safety and performance goals can be met.
Why We Need to View Healthcare as a System
Healthcare is a complex system in which errors can occur if something is poorly designed or used in an unintended way. Problems in one part of the system can create hazards in another part of the system. And, if not discovered, problems in any part of the system could cause harm to patients or clinicians.
This image represents healthcare as a system. Safety science research demonstrates that the most effective, safe, and sustainable system designs consider all components of a work system. In healthcare systems, component include:
- People
- Tasks and processes
- Tools and technology
- Physical environment
- Supporting organizational structure
Outside of these five components, which make up the internal environment, there is an external environment. The external environment contains elements that are outside the internal system yet still affect it. The external environment introduces challenges that cannot be controlled but still must be accounted for in the design of the internal environment.
When you view healthcare as a system, it becomes clear that problems are often more complicated than they first appear. But that means there are more ways to solve those problems than may be apparent at first.
Every healthcare worker is an extremely important part of how well the healthcare system works, and each person has the power to affect safety and quality in their facility. What follows is an example of how the interplay of people and internal and external elements can inadvertently cause patient harm.
System Safety: “Pump” It Up
Consider the infusion pump—a common medical device often seen next to a patient’s bed. The pump is connected to the patient, and a nurse programs the infusion pump to deliver medicine or food at the rate and time prescribed.
A nurse was programming an infusion pump to give 20 mcg of medicine over an hour. But instead of 20, she programmed 200. While some assumed the nurse was careless, a closer look revealed that the infusion pump had a bad design.
As the nurse was programming the pump, she pressed the zero, but the zero didn’t show up on the display. The problem was that the display didn’t show the numbers as quickly as the nurse entered them. She didn’t know that, though; she thought the pump didn’t record her button press. So, she pressed the button again, which entered an extra zero. This is a problem with the “tool and technology” part of the system.
What else was going on? For one thing, the nurse was very busy—as nurses usually are—so she was trying to work quickly. The nurse being very busy is an organizational problem, because the hospital didn’t schedule enough nurses to work that day. That was also part of an external environment problem because there was a shortage of nurses to hire, which caused the hospital to be short-staffed.
This pump mishap was a physical environment problem because the nurse was trying to work across a large hospital floor and get to her next patient down the hall. There was a task and process problem because the method the hospital uses for buying infusion pumps didn’t include a test for usability problems before buying the pump. And there was another external environment problem: that an infusion pump with a poor design could be sold on the market.
That’s a long list of issues, but it’s not exhaustive. There may have been other contributing factors across the system.
If we blamed the nurse and moved on, we wouldn’t know that many issues led to this event. The nurse might be reprimanded and retrained to use the faulty infusion pump. While that might help prevent that nurse from making the same mistake, what happens when a different nurse is using the same infusion pump and has the same problem? Another patient could be harmed.
Designing with Humans at the Center
The infusion pump scenario illustrates the complexities that shape healthcare system safety. By examining the problem from a system perspective, we see that there are many issues to address if we truly want to stop these types of problems from happening again.
Indeed, poor system design is healthcare’s most critical safety challenge. Healthcare takes place in complex sociotechnical environments that stress clinicians, leading to burnout and medical errors. Taking a system perspective enables us to:
- Gain an accurate understanding of how things are working
- Identify contributing factors during data collection
- Craft an expanded solution set
- Achieve effective and sustainable outcomes
For an organization to achieve a goal of total system safety—meaning that the organization enables people to work efficiently and effectively and be able to easily detect and prevent potential harm—it is necessary to design the system to support those safety and reliability goals.
Working collaboratively, human factors engineers and safety teams can take a blended approach that considers both the clinical environment and the organization’s safety infrastructure. Using human factors engineering, it’s possible to transform patient safety by designing a work system that supports health workers in delivering care.
As your healthcare organization works to improve safety, consider engaging human factors engineers from ECRI. We can help you take a truly human-centered, total systems approach to safety. Learn more: https://home.ecri.org/pages/patient-safety-advisory-services