The Human Factors Approach to Error - Essay Example

The Human Factors Approach to Error

Part A: Learning Plan

Safety and Incident Investigation Processes

The individual element technique is critical when examining incidents and safety processes to maximize patient safety and boost healthcare quality. Leape (1997) noted that latent errors indicate design failures, inadequate training, and poor management. It is unproductive to assume that medical workers will not be prone to mistakes if they care and work hard (WHO, 2012). Therefore, it is more productive to conduct thorough root cause analysis while focusing on the human elements. This approach poses numerous benefits, including establishing primary error cases, creating a logical solution, and confirming repeatable and chronological processes for future error detection. Nonetheless, root cause analysis has one main drawback: it assumes and focuses on defect causation and does little to address the environmental conditions exacerbating these causes.

Alternative approaches that also eliminate medical errors include the PDSA method, a cyclical technique that continually modified a change plan. Additionally, the TeamSTEPPS method encourages teamwork during assessment and training to account for medical care’s interdisciplinary nature. Reason (2000) confirmed that most effective healthcare centers use these strategies to direct their resources and ensure their staff members are less fallible. Additionally, Norman (2013) noted that institutions need to investigate mistakes until all underlying causes are revealed. As a result, medical centers can then integrate successful human factors, including situational cognizance, to eliminate mistakes (Bleetman et al., 2012). An in-depth root cause inquiry into personal aspects must entail acknowledging the universal element of fallibility.

How Using the Human Factors Approach Impacts Patient Safety

Unfortunately, patient safety has lost its central focus involving risk management, as more professionals now strive for perfection (Amalberti & Vincent, 2019). However, a root cause examination focused on human aspects attempts to re-introduce the notion of minimizing harm. Patient safety is often a paramount concern for all healthcare centers (ECRI, 2020). Thus, investigating human aspects reveals the connection between individuals and the processes which they encounter. According to Carayon et al. (2013), such a strategy shows the system components that increase medical errors to guide work processes featuring minimal fallacies. The interventions are then guaranteed to improve patient safety since practitioners already acknowledge procedures most likely to cause unwarranted harm. Lastly, in 2015, a Joint Commission found that although individuals are often blamed for decreases in patient safety, errors are often ingrained in an organization’s set-up. Therefore, it is profitable to initiate an analysis that seeks to determine an event’s root causes. Such a step is fruitful since latent mistakes within the center can be addressed.

How Using the Human Factors Approach Impacts Quality

Using this strategy is instrumental in establishing a safety culture that comprises a diagnostic tool that continually manages issues in all work areas. Baysari et al. (2019) affirmed that such an environment is possible if staff members all seek to incorporate interventions that reduce adverse safety incidents. This culture can be created by following a root cause analysis’s processes correctly. Instead of seeking to circumvent protocols, the care providers uphold all regulations despite any inconvenience (Debono et al., 2013). The first step requires defining the issue, gathering information to prove the challenge, and establishing possible causal elements. Carayon et al. (2014) argued that examining structural aspects provides useful data to streamline care techniques. The fourth phase then requires participants to determine why the causal elements exist since the answer to this query is often the root cause. Finally, they can suggest and integrate solutions to effect permanent change within the system. Doing so ensures that care institutions can elevate productivity, creativity, and efficacy while minimizing mistake causes.

Learning Objectives and Interactive Activity

This in-personal seminar will discuss how the human elements strategy is useful in examining medical care incidents. The participants will discuss two case studies as an interactive activity to enhance their comprehension. The first incident will feature a patient who received a carpal tunnel release while the physician should have addressed her trigger finger release (PSNet, 2019c). The second case study involves an obstetric nurse who connected medication intended for an epidural catheter to the patient’s IV line (PSNet, 2019a). The participants will then discuss why these events transpired and how the institutions could have foreseen the outcome.

Therefore, the seminar will feature two distinct learning objectives. First, the attendees will learn why it is critical to follow pre-specified procedures during patient care and justify why these protocols are implemented (PSNet, 2019b). Secondly, the participants will understand how to establish latent errors and utilize their discoveries to ensure patient safety. The training will utilize PSNet’s articles on risk analysis and Bleetman’s, Sanusi’s, Dale’s, and Brace’s academic piece on the same topic.

Part B: Pitch

Topic Summary

The training session will center around examining human aspects and relating them to error incidence among medical providers. The participants will learn how to optimize root cause examinations by discussing this procedure’s benefits and drawbacks. Human components are often primary contributors to adverse incidents, which often have fatal impacts. Therefore, the medical sector can only be made safer by acknowledging practitioners’ potential for error and developing techniques to learn from such circumstances. Since it is possible to manage these aspects, proactive strategies are required to guide professionals’ conduct and inform each institution’s work culture. This seminar training aims to achieve this feat by informing all participants about root cause investigations and alternative methods that achieve similar outcomes. Successful error-reduction programs are only possible if the creators have sufficient information concerning risk analysis and prevention.

Why Topic is Important

It is critical to engage in this in-person, one-day training exercise since it will feature discussions regarding incident analysis and error prevention. Participants will comprehend the significance of in-depth research following an adverse event, even after discovering possible causes. For instance, the professionals will learn how to question why an incident happened, why a different outcome did not manifest, and how the current instance can impact future circumstances. Although this approach does not guarantee success, it ensures the examiner uncovers any latent contributors and begins to find solutions to address each structural component. Most institutions will launch immediate investigations but fail to examine all underlying factors after identifying one human aspect. Therefore, the decision-making that follows is hardly fully informed, implying a similar event with worse consequences is likely to follow even after correction measures are installed.

Furthermore, it is essential for professionals to comprehend this topic extensively because it reiterates the significance of learning from past adverse events to prevent repeat instances. The case studies will entail real-life scenarios whose outcomes may have varied had the systems involved constitute distinct elements. Thus, the participants will gain actionable information from their peers to integrate into their respective care procedures. The case studies will examine why situational awareness is crucial during disaster management and prompt all attendees to connect their daily tasks to these hypothetical situations. Doing so will emphasize the essential tasks they perform and the essential nature of each decision they authorize or implement. These efforts will ensure they can incorporate positive human elements into all patient interactions and cease to struggle to address latent failures in their processes. Hopefully, the knowledge gain can encourage them to advocate for lasting policy alterations for sustainable improvements resulting from reduced reliance on human action.