Patient Safety. a Human Factors Approach

Description

Increased concern for patient safety has put the issue at the top of the agenda of practitioners, hospitals, and even governments. The risks to patients are many and diverse, and the complexity of the healthcare system that delivers them is huge. Yet the discourse is often oversimplified and underdeveloped. Written from a scientific, human factors perspective, Patient Safety: A Human Factors Approach delineates a method that can enlighten and clarify this discourse as well as put us on a better path to correcting the issues.

People often think, understandably, that safety lies mainly in the hands through which care ultimately flows to the patient—those who are closest to the patient, whose decisions can mean the difference between life and death, between health and morbidity. The human factors approach refuses to lay the responsibility for safety and risk solely at the feet of people at the sharp end. That is where we should intervene to make things safer, to tighten practice, to focus attention, to remind people to be careful, to impose rules and guidelines. The book defines an approach that looks relentlessly for sources of safety and risk everywhere in the system—the designs of devices; the teamwork and coordination between different practitioners; their communication across hierarchical and gender boundaries; the cognitive processes of individuals; the organization that surrounds, constrains, and empowers them; the economic and human resources offered; the technology available; the political landscape; and even the culture of the place.

The breadth of the human factors approach is itself testimony to the realization that there are no easy answers or silver bullets for resolving the issues in patient safety. A user-friendly introduction to the approach, this book takes the complexity of health care seriously and doesn’t over simplify the problem. It demonstrates what the approach does do, that is offer the substance and guidance to consider the issues in all their nuance and complexity.

Features

• Covers the difficult connections between error, competence, and identity in healthcare – a mix that makes medicine unique among safety critical worlds
• Presents material written with the medical practitioner in mind
• Includes the latest Human Factors/Ergonomics research applicable to patient safety with examples that connect theory to actual practice
• Discusses accountability and just culture
• Presents information in easy-to-use bulleted lists and illustrations where possible and uses non-specialist language, which makes it accessible to all levels of professions and practitioners in healthcare

Table of Contents

• Medical Competence and Patient Safety
• Competence as Individual Virtue or Systems Issue?
• Why the Difference in Competence Assumptions?
• Good Doctoring and the Pursuit of Perfection
• Standardization and the Fear of Scientific-Bureaucratic Medicine
• The Expectation of Perfection versus the Inevitability of Mistake
• Key Points
• References

• The Problem of "Human Error" in Healthcare
• Numbers Are Strong
• The Human Factors Approach
• Human Error as Attribution and Starting Point
• "I Knew This Could Happen!"
• The Local Rationality Principle
• Key Points
• References

• Cognitive Factors of Healthcare Work
• Attentional Dynamics
• Knowledge Factors
• Strategic Factors
• Key Points
• References

• New Technology, Automation, and Patient Safety
• The Substitution Myth
• Data Overload
• Automation Surprises
• Evaluating and Testing Medical Technology
• Key Points
• References

• Safety Culture and Organizational Risk
• Safety Culture and Drifting into Failure
• Risk as Energy to Be Contained
• Risk as Complexity
• Risk as the Gradual Acceptance of the Abnormal
• Risk as a Managerial or Control Problem
• Key Points
• References

• Practical Tools for Creating Safety
• Safety Reporting and Organizational Learning
• Adverse Event Investigations
• Human Factors and Resource Management Training
• Briefings and Checklists
• Key Points
• References

• Accountability and Learning from Failure
• Learning and Accountability—Just Culture
• Criminalization of Medical Error: A Growing Problem?
• The Second Victim
• Key Points
• References

• New Frontiers in Patient Safety: Complexity and Systems Thinking
• Complicated versus Complex
• Newton, Components, and Complexity
• The Cartesian-Newtonian Worldview and Adverse Events
• Key Points
• References
• Index

Author

Sidney Dekker (PhD, The Ohio State University, 1996) is Professor and Director of the Key Centre for Ethics, Law, Justice and Governance at Griffith University, Brisbane, Australia. He was previously Professor and Director of the Leonardo da Vinci Center for Complexity and Systems Thinking at Lund University, Sweden, and Professor of Community Health Science at the Faculty of Medicine, University of Manitoba, Canada. He has been Visiting Professor at the Alfred Hospital in Melbourne, Australia. He recently became active as airline pilot, flying the Boeing 737.