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Applying human factors engineering to QI
Reduce reliance on memory
What do high-reliability organizations, lean techniques, and Six Sigma have in common? First, they're all part of the discussion of modern quality improvement and change management in health care. Second, they all come from industries such as manufacturing, aviation, and nuclear power.
Barbara Wilson, PhD, RNC, assistant professor at Arizona State University's College of Nursing and Health Innovation, Center for Improving Health Outcomes in Children, Teens, & Families, began focusing on patient safety as a nurse manager and then as a director at Intermountain Healthcare in Salt Lake City. She recognized then that "we had to do something about standardizing care." For instance, within the system one hospital might differ in how it handles induction of labor. "I've really been interested in what are differences in terms of practice variables, and how do we figure out what's the ultimate process for patients and then try to streamline processes so we can consistently achieve that."
She says aviation had been onto this 15 years before health care really caught on. A plane does not take off until a thorough check has been completed. While health care, she says, has used checklists similarly, it was never as consistent or standardized a process. "I think physicians have been more resistant, quite frankly, in my experience to standardize processes because they're training for years and years not in a teamwork environment. They're soloists. And it was very hard when I was an administrator to tell a doctor, 'We're not letting you do it this way. We want to standardize it to this way.' That was hard for a doctor to hear because they called it 'cookbook medicine.'"
With so many variables, though, in the way medicine is practiced, costs and the chance of errors increases, Wilson says. What are practices consistent with human factors engineering? Wilson says:
Prepackaging and standardizing supplies.
"Yet I think there's real hesitancy for hospitals because they don't want to upset the physicians for fear they'll pull their patients out," Wilson says. She recalls working with a physician who did a lot of volume and insisted on using something other than the standard C-section pack because he liked wiping his hands a certain way. "So here the hospital had prepackaged supplies to meet the needs of one physician out of 30. We can't do that kind of stuff."
Ensuring practices are based on evidence-based protocols and double-blind checks on high-risk medications.
For high-risk medications, she suggests using protocols. For instance, stating "Mix this amount of fluid for this medication and run it at a set number of cc's per hour." If a nurse gets a dose that she has to do a calculation on, she can say to another nurse, "this is the math problem. Would you figure it out and then let's see if we get the same results." This type of double checking, Wilson says, is an effective way of preventing problems with high-risk medications.
This, Wilson says, is an opportunity for staff to work on a manikin "so they can learn skills without posting the risk to real patients. It's a structured way to learn that's risk-free in terms of error."
The use of checklists and preprinted order sets.
This reduces reliance on memory and establishes processes "to reduce the likelihood that someone is going to make a mistake." Her caveat: You should not forget the intent of the steps on a checklist. Don't just do it because it's routine. "Be consistent about it, and then when there is a variation, stop the procedure, stop the process immediately until that gets resolved," she says.