physician-patient interaction design: quality of service & error prevention
TRANSCRIPT
HVHF Sciences, LLC
Physician Interactions Medicine as a Sociotechnical
System
Moin Rahman Principal Scientist
HVHF Sciences, LLC
“Designing solutions when stakes are high, moments are fleeting and decisions are critical”
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Medical Sociotechnical System
Physician – Patient
Professionals - support staff - specialists - …..
Technology - sensors - Displays - …..
Infrastructure - physical - virtual - …..
knowledge/skills
procedures
financial
regulations
…..
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Safety
Effectiveness
Productivity
Well being
Goals & Challenges: Medical STS
Minimize errors,
Maximize successful outcomes
Cost effective
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Nurses
216 deaths nationwide from 2005 to the middle of 2010 in which
problems with monitor alarms occurred.”
ALARM FATIGUE
- Boston Globe
15-bed unit at Johns Hopkins Hospital:
- 942 alarms per day
- 1 critical alarm every 90 seconds
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Stress is a construct that refers to one’s response to an
imbalance between the expectations or demands placed on
individuals and the resources or capacities available to meet
them.
STRESS
MISMATCH: DEMAND vs. CAPACITY
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Does nursing workload affect patient outcomes that are related to
patient safety?
- higher rates of non-fatal adverse outcomes
- higher incidence of medication errors.
WORKLOAD
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(AHRQ
- Interruptions: 6.6 times per hour
- 11 percent of all tasks were interrupted
- 3.3 percent of them more than once.
- Multitasking: 12.8 percent of the time
- did not return: 18.5 percent of the interrupted tasks
Source: Wesbrook et al.(2010)
Interrupt-driven Physician-
Patient Interaction
TASK TRUNCATION
INCREASE IN TASK-on-TIME
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1. Filtering
2. Memory management
3. Task switching (impaired)
The Myth of
Multitasking
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Sterile cockpit – below 10,000 feet…
Critical Interactions
“sterile”
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Missed diagnosis (rate of error): 15%
Clinical Dignosis
Man stands in contrast with man-made systems
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(Elstein, 1995)
Overdiagnosis
Predictable trajectory…(swiss cheese model)
Challenges and Errors: error begets error
http://www.sciencedirect.com/science/article/pii/S0010027711001995
American airlines crash Cali…
Heuristics – short cuts – Recognition Primed Decision Making: Fire Fighters
Heuristics & Biases
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Heuristic
Heuristic is a mental shortcut – a rule of thumb -- because the underlying shortcut is typically correct and produces the desired result in most cases with minimum cost, delay, and anxiety.
Heuristics & Biases
Bias
A prejudice, partiality, preconception, conjecture, or prejudgment that leads to misinterpretation.
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Thin slicing
Questioning style
Affective connection
Social Interaction
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Heuristics
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Ratio of words that start with R (“red”) vs. words that R in the third position (“car”)
1:2
Availability Heuristic
Anchoring Heuristic
Premature closure
Heuristics
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Overdiagnosis
Predictable trajectory…(swiss cheese model)
Challenges and Errors: error begets error
http://www.sciencedirect.com/science/article/pii/S0010027711001995
American airlines crash Cali…
Heuristics – short cuts – Recognition Primed Decision Making: Fire Fighters
Heuristics & Biases
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Attribution errors
Affective error
Confirmation bias
Blindness bias
Unaware what we don’t know.
Physician Cognitive Errors (biases)
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Blindness Bias
God grant me the serenity
to accept the things I cannot change;
courage to change the things I can;
and wisdom to know the difference.
- Reinhold Niehbur
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Serenity Prayer
Blindness Bias
To know that one knows what one knows,
and to know that one doesn't know what one
doesn't know,
there lies true wisdom.
- Confucius
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Diagnostician’s Serenity Prayer
Lung Cancer: Surgery or Radiation?
MORTALITY FRAME
10% chance of dying (“dying frame”) 90% chance of survival (“survival frame”)
Surgery Election 58% (“dying frame”) 75% (“survival frame”)
Framing
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Citizens
e.g. health insurance
Public Policy Makers
e.g., homeland security vs. healthcare
Loss Aversion
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42
“Emergency or crisis conditions occur suddenly and often unexpectedly,
operators must make critical decisions under extreme stress, and the
consequences of poor performance are immediate and catastrophic.”
(Salas, Driskell & Hughes, 1996).
Nonequilibrium: Human-Machine Systems
Conventional Wisdom:
Errors were the fault of the person committing
them.
- not the machines they operated
- the procedures that they were given
- the environment in which they worked
Errors: Who is to Blame?
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44,000 - 98,000 Americans die
from medical errors/year
To Err is Human (IOM, 1999)
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"Simply put: humans design, manufacture, train,
operate, manage and defend the system. Therefore,
when the system breaks down, it is of necessity due to
human error somewhere. From this perspective and
depending upon the level of observation, one hundred
per cent of accidents are arguably caused by human
error.“
- ICAO Safety Management Manual (doc. 9859, para. 7.10.6)
The “genesis” of Error
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(Cooks, Woods & Miller)
How were the defenses breached?
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Unsafe Acts
Unintended Action
intended Action
Slip
Lapse
Mistake
Violation
Attentional Failures
Memory Failures
Rule-based mistakes
Knowledge-based mistakes Failures
Routine/Exceptional violations
Sabotage
Taxonomy of Error (James Reason)
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Cultural
Dimension High Low
Power distance + _
Individuality Individualistic Collective
Toughness Masculine Feminine
Uncertainty
avoidance Reliability Novelty
Long-term
orientation
Long term
investments Short term resullts
(Hofstede)
Medical Sociotechnical System
Physician – Patient
Professionals - support staff - specialists - …..
Technology - sensors - Displays - …..
Infrastructure - physical - virtual - …..
knowledge/skills
procedures
financial
regulations
…..
© HVHF SCIENCES LLC, ALL RIGHTS RESERVED 2011