The majority of errors in healthcare are from systems factors that create the latent conditions for error to occur. The majority of occupational stressors causing burnout are also the result of systemic factors. Advan...The majority of errors in healthcare are from systems factors that create the latent conditions for error to occur. The majority of occupational stressors causing burnout are also the result of systemic factors. Advances in technology create new levels of stress and expectations on healthcare workers (HCW) with an endless infusion of requirements from multiple authoritative sources that are tracked and monitored. The quality of care and safety of patients is affected by the wellbeing of HCWs who now practice in an environment that has become more complex to navigate, often expending limited neural resource (brainpower) on classifying, organizing, constantly making decisions on how and when they can accomplish what is required(extraneous cognitive load) in addition to direct patient care. New information demonstrates profound biological impact on the brains of those who have burnout in areas that affect the quality and safety of the decisions they make-which affects risk to patients in healthcare. Healthcare administration curriculum currently does not include ways to address these stress-induced problems in healthcare delivery. The science of human factors and ergonomics (HFE) promotes system performance and worker wellbeing. Patient safety is one component of system performance. Since many requirements come without resource to accomplish them, it becomes incumbent upon health system leadership to organize the means for completion of these to minimize the needless loss of brain power diverted away from the delivery of patient care. Human Factor-Based Leadership (HFBL) is an interactive, problem solving seminar series designed for healthcare leaders. The purpose is to provide relevant human factor science to integrate into their leadership and management decisions to make HCWs occupational environment more manageable and sustainable-which makes safer conditions for clinician wellbeing and patient care. After learning the content, a cohort of healthcare leaders believed that adequately addressing HFE in healthcare delivery would significantly reduce clinician burnout and risk of latent errors from upstream leadership decisions. An overview of the content of the seminars is described. Leadership feedback on usability of these seminars is reported. Three HFBL seminars described are Human Factor Relevance in Leadership, Biopsychosocial Approach to Wellness and Burnout, Human Factor Based Leadership: Examples and Applications.展开更多
Software defect prevention is an important way to reduce the defect introduction rate.As the primary cause of software defects,human error can be the key to understanding and preventing software defects.This paper pro...Software defect prevention is an important way to reduce the defect introduction rate.As the primary cause of software defects,human error can be the key to understanding and preventing software defects.This paper proposes a defect prevention approach based on human error mechanisms：DPe HE.The approach includes both knowledge and regulation training in human error prevention.Knowledge training provides programmers with explicit knowledge on why programmers commit errors,what kinds of errors tend to be committed under different circumstances,and how these errors can be prevented.Regulation training further helps programmers to promote the awareness and ability to prevent human errors through practice.The practice is facilitated by a problem solving checklist and a root cause identification checklist.This paper provides a systematic framework that integrates knowledge across disciplines,e.g.,cognitive science,software psychology and software engineering to defend against human errors in software development.Furthermore,we applied this approach in an international company at CMM Level 5 and a software development institution at CMM Level 1 in the Chinese Aviation Industry.The application cases show that the approach is feasible and effective in promoting developers＇ ability to prevent software defects,independent of process maturity levels.展开更多
This paper discusses some of the key aspects of human factors in anaesthesia for the improvement of patient safety. Medical errors have emerged as a serious issue in healthcare delivery. There has been new interest in...This paper discusses some of the key aspects of human factors in anaesthesia for the improvement of patient safety. Medical errors have emerged as a serious issue in healthcare delivery. There has been new interest in human factors as a means of reducing these errors. Human factors are important contributors to critical incidents and crises in anaesthesia. It has been shown that the prevalence of human factors in anaesthesia can be as high as 83%. Cognitive thinking process and biases involved are important in understanding human factors. Errors of cognition linked with human factors lead to anaesthetic errors and crisis. Multiple errors in the cognitive thinking process, known as "Cognitive dispositions to respond" have been identified leading to errors. These errors classified into latent or active can be easily identified in the clinical vignettes of serious medical errors. Application of the knowledge on human factors and use of cognitive de-biasing strategies can avoid human errors. These strategies could involve use of checklists, strategies to cope with stress and fatigue and the use of standard operating procedures. A safety culture and health care model designed to promote patient safety can compliment this further. Incorporation of these strategies strengthens the defence layers against the "Swiss Cheese" models, which exist in the health care industry.展开更多
Our healthcare delivery system has accumulated complexity of payment, regulation systems, expectations and requirements. Often these are not designed to align with clinical thinking process flow of patient care. As a ...Our healthcare delivery system has accumulated complexity of payment, regulation systems, expectations and requirements. Often these are not designed to align with clinical thinking process flow of patient care. As a result, clinicians are utilizing enormous mental (cognitive) resource to comply with these complexities, over and above the baseline mental effort required to give good care to the patient. Recent studies suggest a significant number of physicians, advanced practice providers and nurses no longer want to stay in healthcare due to difficult work expectations and conditions that have become unreasonable. Technology has benefitted healthcare delivery, but also is a conduit of many expectations that have been grafted upon clinician workloads, exceeding the resources provided to accomplish them. Cognitive load is a measure of mental effort and is divided into Intrinsic, Germane and Extraneous Cognitive Load. Extraneous Cognitive Load (ECL) is what is not necessary and can be removed by better design. High cognitive load is associated with increased risk of both medical error and clinician burnout. Chronic high level occupational stress occurs from dealing with this job/resource imbalance and is showing serious personal health impact upon clinicians and the quality of the work they can provide for patients. Since organizational systems have become more complex, leadership methods, clinician wellbeing and patient safety efforts need to adjust to adapt and succeed. Safety efforts have tended to predominantly follow methods of a few decades ago with predominant focus upon how things go wrong (Safety I) but are now being encouraged to include more of the study of how things go right (Safety II). Human Factors/Ergonomics (HFE) science has been used in many industries to preserve worker wellbeing and improve system performance. Patient safety is a product of good system performance. HFE science helps inform mechanisms behind Safety I and II approach. HFE concepts augment existing burnout and safety interventions by providing a conceptual roadmap to follow that can inform how to improve the multiple human/technology, human/system, and human/work environment interfaces that comprise healthcare delivery. Healthcare leaders, by their influence over culture, resource allocation, and implementation of requirements and workflows are uniquely poised to be effective mitigators of the conditions leading to clinician burnout and latent medical error. Basic knowledge of HFE science is a strategic advantage to leaders and individuals tasked with achieving quality of care, controlling costs, and improving the experiences of receiving and providing care.展开更多
为定量研究海上交通事故人失误致因因素,分析各种人失误因素对事故的影响程度,从而达到控制人失误事故的最终目的.在引入人的不安全行为分类框架和"人—机—环境"系统的基础上,运用人因素分析与分类系统(Human Factors Analys...为定量研究海上交通事故人失误致因因素,分析各种人失误因素对事故的影响程度,从而达到控制人失误事故的最终目的.在引入人的不安全行为分类框架和"人—机—环境"系统的基础上,运用人因素分析与分类系统(Human Factors Analysis and Classification System,HFACS),提出海上交通事故人失误分析与分类系统(Human Error Analysis and Classification System for Marine TrafficAccident,HEACS-MTA),对海上交通事故人失误因素进行分类.运用灰色关联分析法(Grey Rela-tional Analysis,GRA)对事故形成原因进行定量分析,得出管理因素是事故的根本原因.导致事故发生的人失误因素依次为不安全行为的前提条件、不安全的监督、不安全行为和组织影响.展开更多
文摘The majority of errors in healthcare are from systems factors that create the latent conditions for error to occur. The majority of occupational stressors causing burnout are also the result of systemic factors. Advances in technology create new levels of stress and expectations on healthcare workers (HCW) with an endless infusion of requirements from multiple authoritative sources that are tracked and monitored. The quality of care and safety of patients is affected by the wellbeing of HCWs who now practice in an environment that has become more complex to navigate, often expending limited neural resource (brainpower) on classifying, organizing, constantly making decisions on how and when they can accomplish what is required(extraneous cognitive load) in addition to direct patient care. New information demonstrates profound biological impact on the brains of those who have burnout in areas that affect the quality and safety of the decisions they make-which affects risk to patients in healthcare. Healthcare administration curriculum currently does not include ways to address these stress-induced problems in healthcare delivery. The science of human factors and ergonomics (HFE) promotes system performance and worker wellbeing. Patient safety is one component of system performance. Since many requirements come without resource to accomplish them, it becomes incumbent upon health system leadership to organize the means for completion of these to minimize the needless loss of brain power diverted away from the delivery of patient care. Human Factor-Based Leadership (HFBL) is an interactive, problem solving seminar series designed for healthcare leaders. The purpose is to provide relevant human factor science to integrate into their leadership and management decisions to make HCWs occupational environment more manageable and sustainable-which makes safer conditions for clinician wellbeing and patient care. After learning the content, a cohort of healthcare leaders believed that adequately addressing HFE in healthcare delivery would significantly reduce clinician burnout and risk of latent errors from upstream leadership decisions. An overview of the content of the seminars is described. Leadership feedback on usability of these seminars is reported. Three HFBL seminars described are Human Factor Relevance in Leadership, Biopsychosocial Approach to Wellness and Burnout, Human Factor Based Leadership: Examples and Applications.
文摘Software defect prevention is an important way to reduce the defect introduction rate.As the primary cause of software defects,human error can be the key to understanding and preventing software defects.This paper proposes a defect prevention approach based on human error mechanisms：DPe HE.The approach includes both knowledge and regulation training in human error prevention.Knowledge training provides programmers with explicit knowledge on why programmers commit errors,what kinds of errors tend to be committed under different circumstances,and how these errors can be prevented.Regulation training further helps programmers to promote the awareness and ability to prevent human errors through practice.The practice is facilitated by a problem solving checklist and a root cause identification checklist.This paper provides a systematic framework that integrates knowledge across disciplines,e.g.,cognitive science,software psychology and software engineering to defend against human errors in software development.Furthermore,we applied this approach in an international company at CMM Level 5 and a software development institution at CMM Level 1 in the Chinese Aviation Industry.The application cases show that the approach is feasible and effective in promoting developers＇ ability to prevent software defects,independent of process maturity levels.
文摘This paper discusses some of the key aspects of human factors in anaesthesia for the improvement of patient safety. Medical errors have emerged as a serious issue in healthcare delivery. There has been new interest in human factors as a means of reducing these errors. Human factors are important contributors to critical incidents and crises in anaesthesia. It has been shown that the prevalence of human factors in anaesthesia can be as high as 83%. Cognitive thinking process and biases involved are important in understanding human factors. Errors of cognition linked with human factors lead to anaesthetic errors and crisis. Multiple errors in the cognitive thinking process, known as "Cognitive dispositions to respond" have been identified leading to errors. These errors classified into latent or active can be easily identified in the clinical vignettes of serious medical errors. Application of the knowledge on human factors and use of cognitive de-biasing strategies can avoid human errors. These strategies could involve use of checklists, strategies to cope with stress and fatigue and the use of standard operating procedures. A safety culture and health care model designed to promote patient safety can compliment this further. Incorporation of these strategies strengthens the defence layers against the "Swiss Cheese" models, which exist in the health care industry.
文摘Our healthcare delivery system has accumulated complexity of payment, regulation systems, expectations and requirements. Often these are not designed to align with clinical thinking process flow of patient care. As a result, clinicians are utilizing enormous mental (cognitive) resource to comply with these complexities, over and above the baseline mental effort required to give good care to the patient. Recent studies suggest a significant number of physicians, advanced practice providers and nurses no longer want to stay in healthcare due to difficult work expectations and conditions that have become unreasonable. Technology has benefitted healthcare delivery, but also is a conduit of many expectations that have been grafted upon clinician workloads, exceeding the resources provided to accomplish them. Cognitive load is a measure of mental effort and is divided into Intrinsic, Germane and Extraneous Cognitive Load. Extraneous Cognitive Load (ECL) is what is not necessary and can be removed by better design. High cognitive load is associated with increased risk of both medical error and clinician burnout. Chronic high level occupational stress occurs from dealing with this job/resource imbalance and is showing serious personal health impact upon clinicians and the quality of the work they can provide for patients. Since organizational systems have become more complex, leadership methods, clinician wellbeing and patient safety efforts need to adjust to adapt and succeed. Safety efforts have tended to predominantly follow methods of a few decades ago with predominant focus upon how things go wrong (Safety I) but are now being encouraged to include more of the study of how things go right (Safety II). Human Factors/Ergonomics (HFE) science has been used in many industries to preserve worker wellbeing and improve system performance. Patient safety is a product of good system performance. HFE science helps inform mechanisms behind Safety I and II approach. HFE concepts augment existing burnout and safety interventions by providing a conceptual roadmap to follow that can inform how to improve the multiple human/technology, human/system, and human/work environment interfaces that comprise healthcare delivery. Healthcare leaders, by their influence over culture, resource allocation, and implementation of requirements and workflows are uniquely poised to be effective mitigators of the conditions leading to clinician burnout and latent medical error. Basic knowledge of HFE science is a strategic advantage to leaders and individuals tasked with achieving quality of care, controlling costs, and improving the experiences of receiving and providing care.
文摘为定量研究海上交通事故人失误致因因素,分析各种人失误因素对事故的影响程度,从而达到控制人失误事故的最终目的.在引入人的不安全行为分类框架和"人—机—环境"系统的基础上,运用人因素分析与分类系统(Human Factors Analysis and Classification System,HFACS),提出海上交通事故人失误分析与分类系统(Human Error Analysis and Classification System for Marine TrafficAccident,HEACS-MTA),对海上交通事故人失误因素进行分类.运用灰色关联分析法(Grey Rela-tional Analysis,GRA)对事故形成原因进行定量分析,得出管理因素是事故的根本原因.导致事故发生的人失误因素依次为不安全行为的前提条件、不安全的监督、不安全行为和组织影响.
