Patient Safety A Human Factors Approach

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.

Medical Competence and Patient SafetyCompetence as Individual Virtue or Systems Issue?Why the Difference in Competence Assumptions?Good Doctoring and the Pursuit of PerfectionStandardization and the Fear of Scientific-Bureaucratic MedicineThe Expectation of Perfection versus the Inevitability of MistakeKey PointsReferencesThe Problem of "Human Error" in HealthcareNumbers Are StrongThe Human Factors ApproachHuman Error as Attribution and Starting Point"I Knew This Could Happen!"The Local Rationality PrincipleKey PointsReferencesCognitive Factors of Healthcare WorkAttentional DynamicsKnowledge FactorsStrategic FactorsKey PointsReferencesNew Technology, Automation, and Patient SafetyThe Substitution MythData OverloadAutomation SurprisesEvaluating and Testing Medical TechnologyKey PointsReferencesSafety Culture and Organizational RiskSafety Culture and Drifting into FailureRisk as Energy to Be ContainedRisk as ComplexityRisk as the Gradual Acceptance of the AbnormalRisk as a Managerial or Control ProblemKey PointsReferencesPractical Tools for Creating SafetySafety Reporting and Organizational LearningAdverse Event InvestigationsHuman Factors and Resource Management TrainingBriefings and ChecklistsKey PointsReferencesAccountability and Learning from FailureLearning and Accountability—Just CultureCriminalization of Medical Error: A Growing Problem?The Second VictimKey PointsReferencesNew Frontiers in Patient Safety: Complexity and Systems ThinkingComplicated versus ComplexNewton, Components, and ComplexityThe Cartesian-Newtonian Worldview and Adverse EventsKey PointsReferencesIndex

About the 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.