Human Error in Medicine

Question 1

Human error has been responsible for 70% of what type of accidents?

Answer 1

Airline

Question 2

The discipline that deals

with the causes and effects of human error?

Answer 2

human factors engineering (HFE)

Question 3

How many Americans die each year as a result of medical errors?

Answer 3

44,000 – 98,000

Question 4

What is the 8th leading cause of death?

Answer 4

Medical mistakes

Question 5

When we interact with machines or complex systems, we frequently do things contrary to our intentions. This can result in…

Answer 5

Inconvenience or Catastrophe

Question 6

Failure to perform an intended action. It is not defined by an adverse or serious outcome.

Answer 6

Error

Question 7

An unplanned, unexpected, and undesired event. An adverse outcome after an error must be construed to be what?

Answer 7

Accident

Question 8

Percentage of perfusion accidents due to human error?

Answer 8

72.3%

Question 9

Percentage of perfusion accidents due to equipment failure?

Answer 9

19.5%

Question 10

Percentage of perfusion accidents due to indeterminate?

Answer 10

8.2%

Question 11

Input data is are incorrectly perceived, an incorrect intention formed, and the wrong action performed.

Answer 11

Misperceptions

Question 12

Input data correctly perceived, an incorrect intention is formed, and the wrong action performed.
Slip

Answer 12

Mistake

Question 13

Input data correctly perceived, correct intention is formed, and the wrong action performed.

Answer 13

Slip

Question 14

An error which arise from processes inside the actor. The elimination/reduction of such errors must involve psychology, physiology or neurology.

Answer 14

Endogenous Error

Question 15

An error which arise from processes outside the actor. Elimination/reduction of these errors must involve engineering and design of objects and work environment

Answer 15

Exogenous Error

Question 16

leaving out a step

Answer 16

Error of Omission

forgetting to turn on the gas during initiation

Question 17

adding inappropriate step

Answer 17

Error of Commission

Hitting my thumb with a hammer

Question 18

inappropriate adding of a step normally appropriate to a process
(Opening venous line during sucker bypass)

Answer 18

Error of Repetition

Opening the venous line during sucker bypass

Question 19

correct steps, but in wrong order

Answer 19

Error of sequence

Weaning: turning down flow, then increasing the bite on the venous clamp

Question 20

Error of Substitution

Answer 20

omission + commission

Question 21

This failure type are unsafe acts committed by those at the “sharp end” of the system
(air traffic controllers, pilots, anesthesiologists, perfusionists, etc…)

Answer 21

Active Failures

• immediate, short-term effects
• Usually are unique to an event

Question 22

This failure type arise from fallible decisions, usually Created by “top-level” decision makers, those at the “blunt end” (supervisors, managers, administrators). Their consequences may lie dormant for a long time, becoming evident only when they combine with local triggering factors (i.e., active failures, technical faults, atypical system states, etc…)

Answer 22

Latent Failures

• Can lie dormant for many years
• Can contribute to many different events

Question 23

6 Defenses that are measures to protect against hazards and to mitigate the consequences of human failures.

Answer 23

Protection
Detection
Warning
Recovery
Containment
Escape

Question 24

Name 2 Unintended actions?

Answer 24

Slips

Lapses

Question 25

Slips

Answer 25

Attentional intrusions omissions

Question 26

Lapses

Answer 26

``` Memory losing place omitting steps forgetting intentions ```

Question 27

Name 2 intended actions?

Answer 27

Mistakes | Violations

Question 28

Mistakes

Answer 28

Rule-based | Knowledge based

Question 29

Violations

Answer 29

Routine Optimizing Exceptional Sabotage

Question 30

6 Error-producing conditions?

Answer 30

- high workload - inadequate knowledge, ability, or experience - inadequate supervision/instruction - stressful environment - mental state (fatigue, boredom, extreme anxiety) - change

Question 31

7 Violation-producing conditions

Answer 31

- lack of safety culture - lack of concern - poor morale - violation-condoning norms - macho attitudes - poorly expressed rules - priority violation

Question 32

Perfusion Incident rate ?

Answer 32

1 in 1,000 cases Human error = 72.3% Equipment Failure = 19.5%

Question 33

All human beings, regardless of their skills, abilities, and specialist knowledge, make fallible decisions and commit unsafe acts. The human propensity for committing errors and violating safety procedures can be moderated by what 4 items?

Answer 33

Selection Training Well-designed equipment, and good Management, But, it can NEVER be entirely eliminated.

Question 34

Can the human propensity for committing errors and violating safety procedures ever be completely eliminated ?

Answer 34

NO

Question 35

No matter how well designed, constructed, operated, and maintained they all may be, all man-made systems possess ____ ____ in some degree. These failures are analogous to resident pathogens in the human body that combine with local triggering factors (i.e., life stresses, toxic chemicals etc…) to overcome the immune system. Like cancer and cardiovascular disease, disasters in well-defended systems do not arise from single causes. They occur because of the adverse ____ of several factors, each necessary, but none sufficient to breach the defenses.

Answer 35

latent failures conjunction

Question 36

All human endeavors involve some measure of ____ . In many cases, the local hazards are well understood and can be guarded against by a variety of technical or procedural counter-measures. But no one can foresee all the possible accident scenarios, so there will always be chinks in this protective armor.

Answer 36

risk

Question 37

"Even when fatigued, I perform effectively during critical phases of operations/patient care". Who agreed with this statement? Who disagreed with this statement?

Answer 37

Disagreed: Pilots @ 26% Agreed: Surgeons @ 60%

Question 38

"Junior team members should not question the decisions made by senior staff members". Who agreed with this statement? Who disagreed with this statement?

Answer 38

Disagreed: Surgeons @ 55% Agreed: Pilots @ 97%

Question 39

"The level of teamwork and communication with consultant surgeons is high". Who agreed with this statement? Who disagreed with this statement?

Answer 39

Disagreed: Surgical Residents @ 73% Surgical nurse @ 28% Anes. Residents @ 10% Agreed: Surgeons @ 64%

Question 40

The best perfusionists develop what behind the pump ?

Answer 40

A curious and suspicious attitude

Question 41

Human performance is best at what stress level ?

Answer 41

Moderate Stress

Question 42

I have anxiety, stress, and high interest during this ECMO phase.

Answer 42

Phase I (Beginning)

Question 43

The novelty is gone and I feel "hey this isn't so tough" during this ECMO phase.

Answer 43

Phase II ( Middle)

Question 44

I am appropriately vigilant, aware of the unpredictable nature of high tech medicine during this ECMO phase.

Answer 44

Phase III (Maturity)

Question 45

Errors can be moderated by:

Answer 45

* Good training - Continuing education - Wet-labs/emergency drills * Appropriate procedures - Checklists - Protocols - Adoption of new techniques * Well-designed human-machine interface * Identifying potential “latent” error

Question 46

The holes in the defenses are created by what?

Answer 46

* Active failures & | * Latent conditions

Question 47

Low-end solutions focus on ?

Answer 47

those who committed errors or violations.

Question 48

High-end solutions focus on?

Answer 48

systemic problems (latent conditions).