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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
n E
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
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