Human factors research: Keeping patients safe in the face of change
Over the last two decades, the rate of change and complexity in health care has been increasing. Clinicians are becoming more and more specialized, the number and variety of drugs in use have increased, and new technologies have changed the way we deliver care in hospitals, clinics, and even in the homes of patients. These changes enhanced the way medicine is practised; however, some challenges emerged, including increased health care spending.
Understanding how new technologies change the delivery of care is not straightforward. Small changes in one part of the system can introduce major changes in others, shifting responsibility and tasks from one profession to another. Further, new technologies can introduce unexpected errors in some circumstances, but not others.
Fortunately, this is where the science of human factors can play a role. At North York General Hospital, Patricia Trbovich is the Badeau Family Research Chair in Patient Safety and Quality Improvement, and a specialist in human factors. She explains that human factors is the study of how people interact physically and psychologically with products, tools, procedures and processes. In other words, human factors tries to make the environment function in a way that seems natural to people.
“With human factors, we get right into the clinical environment to observe day-to-day health care procedures, run simulations of new ways of doing things, and engage with frontline staff,” says Patricia. “This means that we can better spot why some things are not working well, and suggest changes that are likely to have the approval of health care workers, because they were involved in the discussion.” As a result, human factors methods can reduce errors, improve efficiency, and minimize frustrations experienced by patients and providers. For example, Patricia's team analyzed how to optimally implement smart intravenous infusion pump systems for Health Quality Ontario, and developed evidence-based recommendations for the health system. Read an interview with Patricia Trbovich on her role at NYGH.
Patricia's expert team and collaborators have used human factors methods in a number of other settings. In a recently published article, they describe a novel approach to analyze videos of simulated care to improve patient safety in trauma resuscitation. This new approach is being used to identify breakdowns in the coordination of system elements, such as tools, technology, physical environment and layout, individual skills/knowledge and team interaction. A future article will show how these breakdowns vary across four different scenarios, which challenge the trauma team in different ways.
Changing systems instead of people
Patricia mentions that despite nearly 20 years of focus on health care safety, there is still much progress to be made to reduce harm. To ensure effective corrective actions, the health care system has to place less emphasis on changing people such as imposing actions on the clinicians (e.g., retraining, checklists), and more emphasis on system-based actions (e.g., simplifying processes or improving technology designs to prevent errors). Patricia offers an example from her own research. Before the use of smart infusion pumps, her team noticed physicians were ordering drugs by dose (milligrams), but nurses needed to program the infusion pump by volume (millilitres per hour), thus, often performing calculations when they administered drugs to their patients.
“What we know about human attention, memory, and workload, is that forcing people to do multiple calculations over long 12-hour shifts, while under time pressure, is not an optimal design,” she says. The increasing use of smart infusion pumps in hospitals has helped to address this issue by converting between dose and volume, thus reducing the mental workload on health care workers and the risk of calculation errors.
As the rapid pace of change continues in health care, there will always be cases where systems do not optimally match human abilities. “In the past, when errors occurred in health care, there was a tendency to blame the individual, and administer interventions designed to change the person, rather than look at the overall design of the system,” she says. “This doesn't fix the root cause of the problem; another person, under the same pressures, is likely to make the same mistake. Institutions with a modern outlook are now recognizing that focusing on system designs are actually more humane to their staff, and safer for patients. Human factors is a key strategy for achieving that."
Human factors research at North York General
To bring human factors to NYGH, Patricia's team is using a non-traditional method to study patient safety which will contribute to the identification of new risks in surgery, and help identify and test interventions that may improve care. The method in question is the Operating Room (OR) Black Box®, an innovative observational tool enabling surgical safety research, as part of the newly created Steinberg Family Surgical Safety Program.
Patricia's team together with Dr. Usmaan Hameed and Dr. Lloyd Smith at NYGH, have partnered with the creator of the Black Box, Dr. Teodor Grantcharov from St. Michael's Hospital. NYGH is the second hospital in Canada and North America using this technology, which has similarities to the ones used on airplanes. This project has assembled a team of clinicians, engineers, computer scientists and human factors experts to qualitatively analyze observational data obtained from the Black Box® recordings. This analysis will enable the identification of patient safety threats, challenges in interpersonal and organizational processes, suboptimal technology and environment design as well as factors that enable surgical teams to effectively respond to unanticipated deviations in surgical care.
“I think we are on the cusp of something big in terms of how we study patient safety and I am thrilled that we are doing it here at North York General,” says Patricia. “I am very inspired to reframe how we study patient safety by not only looking at where things go wrong and how we can redesign our systems, but also by looking at all the ways in which our clinicians are resilient and how they do things right.” Read more about the OR Black Box.
NYGH's strategy: Patricia Trbovich's research supports NYGH's strategic pillar to TRANSFORM Care through Applied Research and Innovation and our eHealth strategic foundation. Learn more about our strategy.