QIO HHQI Weekly Update :: October 29, 2007   

TIP OF THE WEEK

Understand human error

Human factors is defined as “the science of designing tools, tasks, information, and work systems to be compatible with abilities of human users; both physical and mental.” [1] Use of human factors engineering is important when an existing process is not producing the desired outcome. Because health care is labor-intensive, the most common errors are those made by people.

A variation of this science is called crew resource management, in use in aviation since the early 1980s, [2] to prevent errors in what was traditionally an industry, which gave full authority to the captain of an airplane. Strengths of other members of the flight crew, which sometimes is simply that one crew member is less distracted than another, are emphasized and each individual is expected to voice observations and make recommendations to prevent accidents.

 

CATEGORIES OF ERRORS IN HUMAN FACTORS

Planning errors
“The process was inadequately put together to achieve the desired outcome.” Planning errors will almost always require some change in the process. Memory aids and additional training may help decrease these types of errors when they arise from an individual’s inability to plan to use the process correctly – when the right supplies are not used, or not enough of the right supplies are taken to the patient’s home.

Execution errors
“The process was not carried out correctly (giving an incorrect medication dose, not including a pain assessment when seeing a patient, forgetting to give an immunization as ordered at the Start of Care).” Execution errors are best remedied by prompts, reminders, and memory aids.

Violation errors
“The person deliberately decided not to follow the correct process, most often because the work-around or failure to provide care is very unlikely to be detected, an inconvenient process, having the authority to violate the specified process, and lack of supervision.”

Violation errors can be decreased by redesigning the workflow, preferably with the persons involved who will be carrying out the process. If there is often a variation in how the process is used, a formal policy may not be desirable as long as staff members understand what the desired outcome should be. Finally, when a process is audited or otherwise monitored, there should be positive reinforcement for those following the process.

The first two types of errors are usually always unintentional, and often are the result of the system in which the process is carried out. Violation errors are usually intentional, yet they may also be the result of the system in which the process is carried out. The most important remedial action for human error is NOT to place blame but to determine what is the root cause of the error.

EXAMPLES

Consider the following scenarios (or similar ones occurring in your agency) and determine what type of error is occurring. There is no one correct answer, as each situation may be caused by something different as well as by multiple failures in the process:

• Clinicians do not consistently educate patients/caregivers on both pharmacological and non-pharmacological methods to relieve pain.
• For many patients with impairment in ambulation/locomotion noted at SOC/ROC, there was no physical therapy referral.
• The home chart is often inaccessible because it gets placed among the patient’s other papers.
• A 72-year-old diabetic patient has an average blood sugar over 2 weeks higher than 350; the hemoglobin A1C in the physician office last week was 11; and tonight the patient has gone to the emergency department with lethargy and dyspnea.
• A 66-year-old patient was sent to the ER on Saturday because the feeding tube came out; he receives all medications and nutrition through the G-tube; he is not febrile nor dehydrated.
• A 48-year-old ESRD patient goes to the ER for a blood pressure of 235/146; she has known about her hypertension for 2 weeks and has become anxious about getting her blood pressure down; she is asymptomatic and not on antihypertensvies.

Sources:

1. MedQIC. Knowledge Net Presentation-Human Factors: Use in Home Health Setting
2. Musson, DM & Helmreich, RL. (2004). Team training and resource management in healthcare: Current issues and future directions. Harvard Health Policy Review, 5, 1, 25-35

 

 

IN THE NEWS

ELDERLY MEDICARE, MEDICAID PATIENTS NOT RECEIVING QUALITY CARE

October 17, 2007 - - Newswire - - If the care received by vulnerable older people concurrently enrolled in Medicare and Medicaid was evaluated on a grading scale, it would squeak by with a barely passing mark, a new UCLA study has found.

Using quality-of-care measurements developed by the Assessing Care of Vulnerable Elders (ACOVE) project, researchers found that vulnerable elderly patients received only 65 percent of the tests and other diagnostic evaluations and treatments recommended for a variety of illnesses and conditions, including diabetes and heart disease. Read more >>.

ADULT DAY-CARE BOOMING

October 14, 2007 - - Cincinnati Enquirer - - One often-overlooked solution to caring for an elderly individual at home is adult day care. But more American families and government leaders are starting to catch on that the options aren't limited to home health care, assisted living facilities, or costly skilled nursing homes. More are discovering -- with great relief -- that adult day centers do vastly more than "baby-sitting" or bingo. Read more >>

 

COMING ATTRACTIONS

   

OCHC: CONNECTING OASIS AND CLINICAL DECISIONS IN THE POST PPS REFORM ENVIRONMENT. October 30, 2007 - - Contact Karen Lowe at 1.614.763.0036, Ext. 206 for more information.

OCHC: Great Lakes Hospice Conference. November 1-2, 2007

OCHC: "OASIS Revisited" Workshop & COS-C Exam. November 8-9, 2007

OCHC: "Hospice 101" Workshop. November 16, 2007

The Many Facets of Pain Management: An Integrated Approach

November 7, 2007, 8:00 a.m. to 4:30 p.m.
MetroHealth Medical Center, Cleveland.
Call (216) 778-7707 for more information.