SIMPLE tool in Simple Way

1. SIMPLE tool in Simple Way Pongtorn Kietdumrongwong, MD

2. Quality is too hard to achieve ? • Too many works • Too many documents • Too many concepts • Too many tools • Too many training • Too many people involved • Too much cost to invest

3. To ease QI process Human factors engineering is about designing the workplace and the equipment in it to accommodate for limitations of human performance

4. Human factors definition • The study of all the factors that make it easier to do the work in the right way • Apply wherever humans work • Also sometimes known as ergonomics

5. Human factors Importance of human factors has been recognized for a long time in: • aviation • nuclear power

6. Importance in health care? • Only recently been acknowledged as an essential part of patient safety • A major contributor to adverse events in health care • All health-care workers need to have a basic understanding of human factors principles

7. Human factors experts Design improvements in the workplace and the equipment to fit human capabilities and limitations Make it easier for the workers to get the work done the right way Decrease the likelihood of errors occurring

8. Examples • order medications electronically • hand off information • move patients If all of these tasks become easier for the health-care provider, then patient safety can improve.

9. I have talked to much theory ! EXAMPLE

10. Avoidable confusion is everywhere… US Department of Veteran affairs

11. Health care is increasingly complex Gaba

12. Human factors design principles • Psychomotor • Hands • Input Devices • Buttons INTERFACE Senses - Vision - Hearing Output - Display - Sound US Department of Veteran affairs

13. Human factors acknowledges: the universal nature of human fallibility the inevitability of error assumes that errors will occur designs things in the workplace to try to minimize the likelihood of error or its consequences

14. Traps in health care? • Look-alike and sound-alike pharmaceuticals • Logistic and Traffic design • Equipment design • e.g. infusion pumps

15. Because the human brain is …. • very powerful • very flexible • good at finding shortcuts (fast) • good at filtering information • good at making sense of things

16. Sometimes though our brain is “too clever” …

17. Are the lines crooked or straight? Optillusions.com

18. Look at the chart Say the colour of the word, not the word itself Why is it hard? Optillusions.com

19. The context of health care When errors occur in the workplace the consequences can be a problem for the patient • a situation that is relatively unique to health care

20. Situations associated with an increased risk of error • unfamiliarity with the task* • inexperience* • shortage of time • inadequate checking • poor procedures • poor human equipment interface * Especially if combined with lack of supervision

21. Apply human factors thinking to your work environment • Avoid reliance on memory • Make things visible • Review and simplify processes • Standardize common processes and procedures • Routinely use checklists • Decrease the reliance on vigilance

22. SIMPLE AS A TOOL TO REDUCE ERROR

23. Checklist

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34. THANK YOU