Patient Safety Competencies Curriculum Development

Domain 5: Optimize Human and Environmental Factors

Key and enabling competencies:

1. Health care professionals who are able to describe the individual and environmental factors that can affect human performance understand:

1.1. The impact of fatigue and other human limitations on clinical performance

1.2. The role of attitude and professional culture in clinical practice

1.3. The role of wellness and its eff ect on knowledge and skill acquisition

1.4. How to integrate coping mechanisms to mitigate performance risks and ambient conditions in various practice environments

2. Health care professionals who apply techniques in critical thinking to make decisions safely are able to:

2.1. Describe the common types of cognitive biases

2.2. Model the behavioural characteristics that demonstrate situational awareness

2.3. Demonstrate a process of sound decision-making, understanding where the process can be challenged and corrected

3. Health care professionals who appreciate the impact of the human/technology interface on safe care are able to:

3.1. Define human factors and human factors engineering and understand their application in health care environments

Learning objectives:

Knowledge

To learn and understand:

1. Factors that aff ect personal well-being, including work-life balance, sleep deprivation/sleep debt, and physical and emotional health
2. Environmental factors such as light and sound, surge conditions, work interruptions and technology that can affect safety
3. Ergonomics, including human factors engineering, system design, technology and work fl ow
4. Critical thinking, including situational awareness and an awareness of cognitive biases in decisionmaking
5. Systems (local, national and international), including their policies and procedures, resource allocation and culture
6. The effect of the acceptance of deviance as the norm and the creation of unsafe work-arounds

Skills

1. To assess personal work-life balance issues and how they aff ect professional performance and the safetyof patients and human performance
2. To identify the normalization of deviance and unsafe work-arounds as they relate to human performanceand culture
3. To identify biases that aff ect decision-making

Attitudes

1. To appreciate that human performance is aff ected by one’s behaviour within a system constructed by resources, culture and policy

Content:

1. Lessons learned from aviation and other industries
2. Fatigue issues
3. Human factors issues

Teaching methodologies:

1.     Introductory 1 or 2 hour interactive, seminar format:

• Present Ben Kolb's case attached and have residents identify issues related to the case.
• Show the Beyond Blame video
• Use the facilitator's guide to return to the case and help identify issues and related competencies

2.    Seminar 1 hour:

• Use human factors slide deck to explain the basics of the impact of human factors.
• Facilitate a discussion on faculty and residents' experiences in their personal /professional/work environment, demonstrate using a piece of
• Equipment e.g.epipen and how mistakes can be made.
• Pre or post session read Reason's article Qual Saf Health care 1995, included below

3.    Journal club 1 hour:

• Use article attached re fatigue issues to critique article
• Facilitate a discussion of fatigue issues, residents' experiences in how this might affect performance

Evaluation:

Learner

Program/session/module

Supporting materials/videos etc:

• Beyond Blame Video $45.00 US ISMP
• Misread Label - IHI Case Study - Available at no charge from IHI Website but you must register

Domain 5 Attachments

HUMAN FACTORS PPT - Sue Tallett & Anne Matlow.pdf
Human Error Reason.pdf
Human Errors PPT - Sue Tallett.pdf
Story of Ben Kolb - Facilitators Guide - Sue Tallett.pdf
Story of Ben Kolb.pdf