Human factors , patient safety

and quality improvement.

understanding the key elements

Moderator : Lt. Col. Asso. Prof Dr. Bikash Bikram Thapa

Presenter: Dr. Adina Bataju

Resident Genral Surgery
Human factors

• Human factors refer to the study of how people interact with systems,
products, and environments.

• In healthcare, it involves understanding how healthcare professionals,

patients, and technologies interact within the healthcare system.
• Healthcare workers must understand that patients are increasingly better
informed and wish to be included more fully within the decision-making
processes regarding treatment options.

• A better understanding of the e ects of teamwork, tasks, equipment,

workspace, culture and organisation on human behaviour will improve
performance in clinical settings.
•
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• HF was originally conceived in the 1940s in the aviation industry to better
understand the relationship between a team’s behaviour, its technical
surroundings and a changing environment.

• The ‘cognitive skills’ of the aircraft crew refers to the mental processes used
for gaining and maintaining situational awareness, for solving problems and
for making decisions,

• whereas ‘interpersonal skills’ are the communications and behavioural

activities associated with teamwork.
•
 • Crew resource management (CRM) training was developed to build
e ective communication skills and a cohesive environment among team
members and to build an atmosphere in which all personnel feel empowered
to speak up when they suspect a problem.
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• More recent developments in HF have looked more closely at designing
systems better suited to minimising error.

• The nudge theory, introduced by Richard Thaler and Cass Sunstein, is

based on shaping the environment to encourage choice selection along
pathways deemed to be benefcial to the individual, an organisation or society.

• A key feature of nudge theory is to structure the selection of preferred options

while allowing individuals to maintain freedom of choice within the decision-
making process.
•
• It is now widely recognised that HF need to be considered in every aspect of
surgical care if the highest standards in patient safety are to be achieved.

• However, safety is just one aspect of a wider HF systems approach to

equipment, task, environment and organisational design.

• Better understanding of HF can also signifcantly contribute to the quality,

accessibility and cost of healthcare services and to the recruitment and
retention of healthcare staf.
•
Patient safety

• the discipline focused on preventing harm to patients during their healthcare

journey, including diagnosis, treatment, and post-care.

• Medicine will never be risk-free. From the beginning of train- ing, doctors are
taught that errors are unacceptable and that the philosophy of primum non
nocere (frst, do no harm) should permeate all aspects of treatment.

• Yet, worldwide, despite all the improvements in treatment and investment in

technologies, training and services, there remains the challenge of dealing
with unsafe practices, incompetent healthcare professionals, poor
governance of healthcare service delivery, errors in diagnosis and treatment
and non-compliance with accepted standards.
• When errors occur, it is important that there are systems in place to ensure
that all those a ected are informed and cared for, and that there is a process
of analysis and learning to uncover the causes and prevent recurrence of
such events.

• The study of patient safety is now a healthcare discipline in its own right,
encompassing patient safety methodologies, health service design, investiga-
tion of incidents and related research.
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• The development of risk management strategies within the healthcare setting
attempts to address these failings.

• Comprehensive risk management is not just an exercise in ligation avoidance

but aims to develop a cultural awareness and support for all healthcare
workers in de ning and delivering high-quality clinical care.
•
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• in 2017 the Organisation for Economic Co-op- eration and Development
(OECD) published The Economics of Patient Safety, which indicates that this
is a problem faced in all healthcare systems, with iatrogenic patient harm
being the 15th leading cause of the global disease burden and accounting for
15% of all OECD countries’ hospital expenditure.
•
Factors that contribute to patient safety incidents.
Human factors

•Inadequate patient assessment; delays or errors in diagnosis

• Failure to use or interpret appropriate tests
• Error in performance of an operation, treatment or test
• Inadequate monitoring or follow-up of treatment
• Defciencies in training or experience
•Fatigue, overwork, time pressures
•Personal or psychological factors (e.g. depression or drug abuse)
•Patient or working environment variation
System failures

• Poor communication between healthcare providers

•Inadequate sta ng levels
•Disconnected reporting systems or over-reliance on automated systems
•lack of coordination at handovers
•Drug similarities
•Environment design, infrastructure
•Equipment failure owing to lack of parts or skilled operator
• Cost-cutting measures by hospitals
•Poor governance structures and inadequate systems to report and review patient
safety incidents
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Medical complexity

• Advanced and new technologies

• Potent drugs, their side e ects and interactions
• Working environments – intensive care, operating theatres
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• Of these, inadequate communication between healthcare sta ,
or between medical sta and their patients or family members,
ranks highest in frequency.
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Understanding patient safety incidents
• Errors can be viewed from a person-centred or a system approach
• The majority of near misses or adverse events are due to system factors
• Understanding why these errors occur and applying the lessons learnt will
prevent future injuries to patients

• It is important to report all near misses or adverse events so that we can

constantly learn from mistakes

• Error models can help us understand the factors that cause near misses and
adverse events

• Examining what works well may be an additional constructive approach to

defning safe patient pathways
Strategies for patient safety

• WHO has established a number of international initiatives for patient safety,

including the surgical safety checklist

• seek opportunities for certifcation and accreditation from national and

international healthcare quality improvement organisations

• Engage with available national and international audits

• Seek collaboration with recognised training bodies and quality
improvement organisations
specific issues in communication

• Professional behaviour and maintaining tness to practice

• Professionalism is an important component of patient safety. This embraces attitudes
and behaviours that serve the patient’s best interests above and beyond other
considerations.

• Fitness to work or practice – competence – refers not just to knowledge and skills but
also to the attitudes required to be able to carry out one’s duties

• Healthcare workers are required to have transparent systems in place to identify,

monitor and assist them to maintain their competence. Credentialing is one way to
ensure that clinicians are adequately prepared to safely treat patients with particular
problems or to undertake defned procedures.
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 Communicating openly with patients and their carers and obtaining consent

• A patient-centred approach by medical sta , with involvement of patients

and their carers as partners, is now recognised as being of fundamental
importance.

• There are better treatment outcomes and fewer errors when there is good
communication, while poor communication is a common reason for patients
taking legal actions.

• Involving patients in and respecting their right to make decisions about their
care and treatment is crucial.
•

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Information to be provided when seeking consent for surgery.
• The condition and the reasons why it warrants surgery.
• The type of surgery proposed and how it might correct the
condition.

• The anticipated prognosis and expected side e ects of the

proposed surgery.

• The unexpected hazards of the proposed surgery.

• Any alternative and potentially successful treatments other than
the proposed surgery.
• The consequences of no treatment at all.
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When things go wrong: open disclosure

• Communicating honestly with patients after an adverse event, or

open disclosure, includes a full explanation of what happened, the
potential consequences and what will be done to x the problem

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Situational awareness: understanding the work environment and
working well within it

• Situational awareness describes an awareness of all individuals within

the environment and an appreciation of the importance of change with
time.

• Emotional intelligence, as defned by Peter Salovey and John Mayer, is

‘the ability to monitor one’s own and other people’s emotions, to
discriminate between diferent emotions and label them appropriately, and
to use emotional information to guide thinking and behavior’.

• Experienced clinicians and clinical leaders understand that excellent

communication skills are based on both situational awareness and
emotional intelligence.
• These features of situational awareness and emotional intelligence are important in
identifying stress within oneself and other members of the healthcare team.
• Stress, tired- ness and mental fatigue in the workplace are signifcant occupational
health and safety risks in health care.
• There is good evidence linking tiredness with medical errors. Fatigue can also afect
well-being by causing depression, anxiety and confusion, all of which negatively impact
on clinicians’ performance.
• Increasingly ‘burnout’ has been identifed as a major cause of poor performance in the
medical workforce.
• Burnout is characterised by a state of emotional, mental and physical exhaustion
caused by prolonged stress.
• Burnout in the medical workforce has increased in recent years and has been
attributed to lack of autonomy within the profession and increased administrative
workloads; the latter is compounded by electronic record-keeping and working in an
increasingly regulated environment. Doctors su er from burnout to a greater extent
than other professions.
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Prescribing safely
Patients are vulnerable to mistakes made in any one of the many steps involved in the
ordering, dispensing and admin- istration of medications. Medication errors are one of
the most common errors across all medical specialties. Accuracy requires that all steps
are correctly executed. Common medi- cation errors include:

• poor assessment or inadequate knowledge of patients and their clinical conditions;

• inadequate knowledge of the medications;
• dosage calculation errors;
• illegible handwriting;
• confusion regarding the name or the mixing up medications.
PATIENT SAFETY AND THE SURGEON: PROFESSIONAL RESPONSIBILITY

• Among medical specialties, surgery is one of the most invasive healthcare

interventions that a patient can experience.

• Problems associated with surgical safety in resource- rich countries account

for half of the avoidable adverse events that result in death or disability.

• The ‘more than one cause’ theory of accident causation can be aptly applied
to many aspects of surgical patient care during the perioperative period.
However, irrespective of the safety event or issue, the surgeon as the likely
senior team leader will play a key role in reporting and communicating these
events with patients and carers, other team members and hospital
administration. This is particularly so for those so-called ‘coal-face’ errors
where patients identify the surgeon as being responsible for a defned episode
of care.
Cuschieri and others have described coal-face errors as those that can potentially
be committed by surgeons during the care of their patients and include:

• diagnostic and management errors;

• resuscitation errors;
• prophylaxis errors;
• prescription/parenteral administration errors;
• situation awareness, identifcation and teamwork errors;
• technical and operative errors.
•
Situation awareness: identifying teamwork errors

Operating theatres have been described as ‘among the most complex political, social
and cultural structures that exist, full of ritual, drama, hierarchy and too often con ct’
• Well- recognised and potential errors include
• the wrong patient in the operating theatre;
• surgery performed on the wrong side or site;
• the wrong procedure performed;
• failure to communicate changes in the patient’s condition;
• disagreements about proceeding;
• retained instruments or swabs

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• All these events are catastrophic for the patient and almost invariably occur
through a lack of communication (see Never events). This means that all
theatre staf should follow proto- cols and be familiar with the underlying
principles supporting a uniform approach to caring for patients.
•
 Technical and operative errors

• In surgery, the person rather than systems approach emphasises the

accountability of the surgeon, who, unlike colleagues in other medical
disciplines, when operating carries specifc responsibilities.
•

•
• Central to operative performance is pro ciency, an acquired state, honed by
sound teaching, practice and repetition, by which a surgeon consistently
performs operations with good outcomes.

• In cognitive psychology, high surgical profciency is a state of automatic

unconscious processing, with the execution being efortless, intuitive and
untiring, as opposed to non-profcient execution, which is characterised by
conscious control processing, requiring constant attention and resulting in
slow, deliberate execution and inducing fatigue. The transi- tion from one
state to the other is better known as the ‘learning curve’ and is refected in the
hierarchal pyramid of competence .

• This should not carry negative connotations for trainee surgeons, who might
be at the conscious processing stage but still perform a perfectly good
operation, although it might take longer and be more tiring
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Failures in operative technique include:

• cognitive errors of judgement, such as late conversion of a di cult laparoscopic procedure

into an open one;

• procedural, when the steps of an operation are not fol- lowed or are omitted;
• executional, when, for example, too much force is used, which may result in damage that
may or may not have consequences;

• misinterpretation of anatomy/pathology, which is compounded by minimal access surgery

with the limita- tions of a two-dimensional image;

• misuse of instrumentation, such as with energised dissec- tion modalities (e.g. diathermy);
• missed iatrogenic injury either at the time of surgery or diagnosed late.
•

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never events

• Many national health services and institutions now require that all incidents are managed,
reported and investigated. Incidents can be de ned as events that could have or did result in
unintended and/or unnecessary serious harm

• One subset of serious incidents is a never or serious reportable event.

• These events are considered to be wholly preventable; for example, a retained abdominal
swab or instrument, where guidance providing strong systemic protective barriers should have
been implemented, namely checklists. Each ‘never event’ type has the potential to cause
serious harm to the patient or even death.

• However, serious harm or death is not required to have occurred for that incident to be
categorised as a ‘never or serious reportable event’. As previously described clinical incidents
of this nature, by defnition, mandate an open disclosure process with patients and their carers.
•
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 QUALITY IMPROVEMENT

• In health care, quality improvement is defned as the continu- ous and

combined eforts of people to make changes that will lead to better patient
outcomes, enhanced healthcare system performance and better learning and
professional development.
•
Measuring clinical outcomes as part of a quality improvement
cycle can help to:
• improve the quality of clinical care, with shorter hospital stays, better outcomes and
fewer complications, reduced readmissions and greater patient satisfaction;

• inform the development of national clinical audits, includ- ing driving participation,
data completeness and accuracy; support shared decision making and
empowerment of patients, including their treatment options and choice of provider;

• improve the oversight and management of clinicians, their teams and practises, thus
reassuring patients that their clinical care is being actively monitored and improved;

• help medical specialty associations to become increasingly transparent and patient

focused;

• support team and individual quality improvement, includ- ing providing information
for appraisal and revalidation;

• learn from, spread and celebrate best practice.

 QUALITY MEASURES

• Measurement is a key principle of quality improvement

• Quality measures are tools that help to quantify the char- acteristics of high-
quality health care and may measure the healthcare process, its outcomes,
the patient’s experience or the organisational structures or systems that
support care delivery.

• Quality may be measured in terms of structure, process and outcomes.

•

•
• Structural measures outline the characteristics of the health system that
afect the system’s ability to meet the healthcare needs of individual patients
or a population.
•
Process measures assess what the healthcare provider did for the patient
and how well it was done. Each surgical patient’s journey is a composite of
multiple processes, such as preoperative assessment, hospital admission and
undergoing an operation, among others.
•
• Outcome measures describe the efects of care on the health status of
patients and populations – they are specifc, observable and measurable
changes that represent the achievement of an outcome of a quality
improvement initiative. Clinical outcome measures refer specifcally to
outcomes of healthcare interventions, whether they are to do with diagnosis,
treatment or care received by service users.

• Outcome measures are what are commonly used in clinical audit when
outcomes achieved are compared with evidence- based standards of clinical
care.

•
 THE PROCESS OF SURGICAL CARE

• Patients attend surgeons in many diferent settings depending on whether they present
electively (scheduled) or urgently (unscheduled).

• electively : If a surgical procedure is required, the patient undergoes assessment from

both a surgical and anaesthetic perspective prior to admission. Ideally the patient is
then admitted in a timely manner to the level of care that best meets their needs,
whether as a day case, on the day of surgery, or for as short a time as possible before
surgery as an inpatient.

• Preoperative checking is followed by the theatre journey, which includes reception,

anaesthesia, the surgery itself and recovery – each, in their own way, a series of
complex interventions. Returning to the ward and recovery demands another set of
skills, procedures and processes followed by a nal ‘discharge from hospital’ process
and transition of care back to the community services if required.
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• The urgent, emergency or unscheduled patient journey is di erent because it
is unpredictable for each individual, although patterns of presentation do
emerge when managing large numbers.

• The patient commonly presents at the emergency department of a hospital

either as a self-referral, as a primary care referral or by ambulance. The
journey begins with triage by a team, who assess the severity of the illness
and then stream the patient to the most appropriate area for their needs,
which might include, for example, a resuscitation unit, a rapid assessment
and treatment unit, an acute surgical assessment unit, a minor injuries unit or
an ambulatory care unit. The objective is that the patient is seen as soon as
possible by a senior decision maker, so that the patient can be treated or
discharged as expeditiously as possible or, if admission and surgery are
required, this too can be expedited. Thereafter, the journey follows a similar
course to that of an elective admission.

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 THE QUALITY IMPROVEMENT PATHWAY

• Quality improvement can be applied to almost any step, process or activity.

•
Healthcare Improvement Scotland identifes seven stages when undertaking
improve- ment:
•
1 discovering – is about defning the aims and vision; understanding what the
problem is and what data are available;

• 2 exploring – is about defning the present state and visu- alising the future state;
• 3 designing – is about defning how to move from the pres- ent state to the future
state and identifying the priorities;
•
• 4 refning – is about testing change, learning from the data and identifying the benefts;
• 5 introducing – is about managing communications and building the will and culture to
change;

• 6 spreading – is about showing the improvements, telling the story and disseminating
the message;

• 7 closing – is about capturing and sustaining the learning.

• Each step is supported by the use of tools and methodologies that are appropriate to
the design and planning of each step, depending on the improvement exercise being
undertaken
•
 Seven types of waste in health care and possible solutions.

• Overproduction
• Example: ordering unnecessary preoperative tests
Solution: implementation of evidence-based preassessment pathways

• Inventory
• Example: storing excessive medication or supplies in ward storage with a risk
of them going out of date
Solution: alphabetically ordered medication cupboards with small amounts of
commonly used drugs in conjunction with an e cient replenishment system
•

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• Waiting
• Example: patients waiting long periods to come to theatre
Solution: staggered admission times aligned to operating theatre schedule

• Waste of transportation
• Example: using trolleys to bring ambulatory day patients to the operating
theatre Solution: better design of the admissions process to enable patients
to walk to theatre
• Waste of overprocessing
• Example: using computed tomography scans to assess children with possible
appendicitis Solution: consider whether ultrasound could be used instead

• Defect
• Example: patients arriving for surgery with incomplete or inappropriate
preoperative paperwork Solution: more robust checking systems before
patients come to theatre
•
• Motion
• Example: frequent searching in theatres and the anaesthetic room to fnd
necessary drugs and equipment
Solution: an e cient theatre layout, common to all operating theatres in the
hospital, where everything needed is easily available with minimal movement
and always in the same place
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thankyou