Term
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Definition
1) Understand errors and system failures
2) Describe range of performance shaping factors that can contribute to suboptimal performance
3) Understand the role of poor design in events related to technology and processes
4) Describe how safety, production pressure, & cost pressure can interact to yield unsafe conditions
5) Describe hierarchy of intervention effectiveness |
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Term
| Structure of Human Brain predisposed to error |
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Definition
• Must rely on limited senses
• Selective attn.
• Recall by association
• Conflict resolution via frequency gambling
• Most conscious processing done by inference
• Memory remodeling over time |
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Term
| Humans bring to every interaction… |
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Definition
• Expectations, beliefs, and preferences
• Variable responses to external stressors and performance shaping factors
• Strong influence of situational factors, context, and contingencies |
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Term
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Definition
1) Cognitive Psychology: slips/mistakes
2) Error Mode: omission, repetition, substitution, commission
3) Error Type: fixation, diagnostic, therapeutic
4) Rasmussen: knowledge, rule, skill-based
5) James Reason: active, latent, system |
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Term
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Definition
• Unexpected events and human errors = inevitable
• Majority of errors do not result in adverse outcomes
• Adverse outcomes result from chain of interacting factors
• Increasing R&D are focused on error recovery strategies |
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Term
| Performance Shaping Factors |
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Definition
• Individual
• Tasks/processes
• Local environment
• Equipment/Technology
• Interpersonal/Team
• Organizational
• Societal |
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Term
| Clinicians not at best due to: |
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Definition
• State of health
• Substance abuse
• Fatigue
• Sleep Deprivation - 21 hrs = drunk
• Mood |
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Term
| Effects of Fatigue/Sleep Deprivation on Clinical Performance |
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Definition
• Slower work pace & less efficient
• Job stress and job dissatisfaction
• More errors and adverse events
• Automobile accidents post-call |
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Term
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Definition
• Negative mood adversely affects the motivation to perform
• Sleep deprivation/fatigue are associated with more negative mood
• Negative mood can be due to both antecedent and contextual factors |
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Term
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Definition
• Crowding
• Clutter
• Disorganization
• Noise
• Interruptions & distractions |
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Term
| Human Factors Design Principles (10) |
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Definition
• Meet users’ needs
• Be visible
• Design for error
• Keep it simple
• Be consistent
• Communicate
• Fail gracefully
• Minimize workload
• Automate wisely
• Focus on core tasks |
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Term
| Obstacles to Effective Communication (5) |
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Definition
• Different perspectives
• Competing goals/priorities
• Stress & time pressure
• Interruptions/distractions
• Communication skills |
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Term
| The C’s of Effective Teamwork (8) |
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Definition
• Competency
• Commitment
• Communication
• Coordination
• Collaboration
• Cooperation
• Conflict
• Culture |
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Term
| Medicine lags other high-risk industries in 3 key ways: |
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Definition
1) Novice practitioners learn in the operational environment
2) Outcomes and safety rely on multidisciplinary teams yet almost no formal team training occurs
3) Limited objective measures of training success and continued competence |
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Term
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Definition
• Production pressure
• Misplaced priorities
• Inappropriate incentives/disincentives
• Over-emphasis on policies, procedures, and training |
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Term
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Definition
1) Humans are essential element in every complex system
2) Many factors can degrade human performance and thus degrade system performance
3) Improving performance requires a thorough understanding of these performance shaping factors |
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