Understanding the concepts of Human Factors is imperative to building safe processes for both patients and staff. The concept of the Dirty Dozen from the Federal Aviation Administration provides a solid foundation for understanding human factors and identifying ways to increase the safety of our processes. The twelve concepts include: fatigue; stress; complacency; communication; awareness; distraction; lack of knowledge; teamwork; lack of resources; pressure; lack of assertiveness; and norms. Case studies will demonstrate how human factors can be used as educational frameworks for staff as well as serve a basic foundation for root cause analysis and understanding how events occur.
Tool: Root Cause Analysis. There is a section of this document that focuses on Human Factors and helps the organization understand some of the reasons why events occur. Thus, understanding human factors is essential to developing and implementing safe processes of care for both patients and staff
Problem: We are trying to implement processes and procedures that can be hardwired to reduce the potential of a human factors error occurring in the course of care. The goal is to make it easy to do the right thing and hard to do the wrong thing and reduce human factors.
Tool Selection: The Root Cause Analysis tool provides an excellent framework for identifying how human factors played a role in the development of an error. Once that factor is identified, then processes can be hardwired to prevent them from happening again or reduce the rate of occurence.
Usage: At our organization, we have embedded Human Factors training into all aspects of our educational programs and activities. The goal is for staff and leaders to understand the importance of Human Factors in the care of patients and the importance of ensuring that we look at these opportunities in detail.
Results: The education we do on Human Factors provides a foundation for staff and leaders to look at their processes and ensure that the safest and most efficient ways have been implemented. Reinforcement of human factors occurs during all RCAs and event reviews to continue to ratchet down on safety.
