However, the system did not reliably scan IV bags. Nurses therefore developed a workaround for urgent situations, whereby they would administer the IV medication without scanning the bar code, and only later manually document its administration. This workaround was deemed to be a substantial contributor to the ultimately fatal error.
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Forcing functions —An aspect of a design that prevents an unintended or undesirable action from being performed or allows its performance only if another specific action is performed first. For example, automobiles are now designed so that the driver cannot shift into reverse without first putting his or her foot on the brake pedal.
Forcing functions need not involve device design. One of the first forcing functions identified in health care was the removal of concentrated potassium from general hospital wards. This action helps prevent the inadvertent addition of concentrated potassium to intravenous solutions prepared by nurses on the wards, an error that has produced small but consistent numbers of deaths for many years.
Standardization —An axiom of human factors engineering is that equipment and processes should be standardized whenever possible, in order to increase reliability, improve information flow, and minimize cross-training needs. Standardizing equipment across clinical settings as in the defibrillator example above is one basic example, but standardized processes are increasingly being implemented as safety measures. The widening use of checklists as a means of ensuring that safety steps are performed in the correct order has its roots in human factors engineering principles.
Resiliency efforts —Given that unexpected events are likely to occur, attention needs to be given to their detection and mitigation before they worsen. Rather than focus on error and design efforts to preclude it, resiliency approaches tap into the dynamic aspects of risk management, exploring how organizations anticipate and adapt to changing conditions and recover from system anomalies. Building on insights from high-reliability organizations, complex adaptive systems , and resourceful providers at the point of care, resilience is viewed as a critical system property, reflecting the organization's capacity to bounce back in the face of continuing pressures and challenges when the margins of safety have become thin.
Despite the above examples, it is generally agreed that human factors principles are underutilized in examination of safety problems and in designing potential solutions.
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The ever-lengthening list of unintended consequences of CPOE can, in part, be viewed as a failure to appropriately design such systems with human factors in mind. Last Updated: September Human Factors Engineering. Approach to Improving Safety.
Facebook Twitter Linkedin Email. Background An obstetric nurse connects a bag of pain medication intended for an epidural catheter to the mother's intravenous IV line, resulting in a fatal cardiac arrest. Applications of Human Factors Engineering to Improving Safety The very nature of human factors engineering precludes "one size fits all" solutions, but several tools and techniques are commonly used as human factors approaches to addressing safety issues.
Resource Type. Patient Safety Primers. Related Resources. Hospital Quality Institute. October , Golden 1 Center, Sacramento, CA. Survivability attributes are those that contribute to the survivability of manned systems DAU Prevalent issues include noise, chemical safety, atmospheric hazards including those associated with confined space entry and oxygen deficiency , vibration, ionizing and non-ionizing radiation, and human factors issues that can create chronic disease and discomfort such as repetitive motion diseases.
Many occupational health problems, particularly noise and chemical management, overlap with environmental impacts. Human factors stresses that creating a risk of chronic disease and discomfort overlaps with occupational health considerations DAU Personnel: Personnel factors are those human aptitudes i. Personnel factors are used to develop occupational specialties for system operators, maintainers, trainers, and support personnel DAU The selection and assignment of personnel is critical to the success of a system, as determined by the needs set up by various work-related requirements.
Training: Training is the learning process by which personnel individually or collectively acquire or enhance pre-determined job-relevant knowledge, skills, and abilities by developing their cognitive, physical, sensory, and team dynamic abilities. It includes the "tools" used to provide learning experiences, such as computer-based interactive courseware, simulators, actual equipment including embedded training capabilities on actual equipment , job performance aids, and Interactive Electronic Technical Manuals DAU Personnel factors are those human aptitudes i.
Manpower describes the number and mix of personnel required to carry out a task, multiple tasks, or mission in order to operate, maintain, support, and provide training for a system. Department of Defense DoD. February 19, US Air Force.
Edward P. Fitts Department of Industrial and Systems Engineering
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