1. To Err Is Human: Building a Safer Health System CIS 763 Fall 2001 Prof. D. Kopec Class presentation By Inna Krayko

2. Introduction  It is in a human nature to make errors.  Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing.

3. Errors in Health Care  Errors in health care is a leading cause of death, injury and more.  High costs of medical errors.  Errors lead to loss of trust in the system and decreased satisfaction.

4. Errors in Health Care (Cont)  Errors can happen in all stages in the process of care.  People can learn from analyzing the errors.

5. How Do the Accidents Happen?  Making a safer system vs. Looking for one to blame.  Quick review of complex systems vs. simple systems.

6. Safer System Design  The safer systems could be designed, if we keep in mind the following: Every device should be designed in the way that it would fall to a safe default situation in case of the error. Shield the internal complexity of the system from operator. Sufficient training as well as properly documented procedures.

7. Human Factors  Research on human factors and how people interact with the systems in the medical industry is a new trend. Two approaches have typically been used in human factor analysis:  Critical incident analysis.  Naturalistic decision making.

8. Creating Safety Systems in Health Care Organizations  Establishing a reporting system.  Such systems have three purposes: Provide the public with a minimum level of protection by assuring that the most serious errors are reported and investigated and appropriate follow up action is taken. Provide an incentive to health care organizations to improve patient safety in order to avoid the potential penalties and public exposure. Require all health care organizations to make some level of investment in patient safety.

9. Guidelines for Designing a Safe Health Care System  Providing leadership  Respect human limits in process design  Promote effective team functioning  Anticipate the unexpected

10. Conclusion  Humans are usually being blamed for errors while using sophisticated systems, but their errors are the ending point of a long chain of circumstances and system specific component flows.  The system have become so complex that without proper design, documentation and testing of every component and the entire system as a whole, the tragic accidents will continue to happen whether we like it or not.  On the other hand the human factor is highly important as well. Properly organized and developed standards and procedures, adequate training and proper monitoring systems, corporate culture health and initiatives, will promote the safe and healthy working environment.

11. References  “To Err Is Human: Building a Safer Health System” By Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors: Committee on Quality of Health Care in America, INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS, ISBN 0-309-06837-1, Copyright 1999 by the National Academy of Sciences.  “Preventing Medical Injury “, by Leape, Lucian, Lawthers, Ann G., Brennan, Troyen A., et al.., 1993.  “Measuring the Quality of Health Care”, by Molla S. Donaldson (1999, ISBN 0309063876).  “America's Health Care Safety Net: Intact but Endangered”, by Marion Ein Lewin and Stuart Altman (2000, ISBN 030906497X),  “Preparing for the 21st Century: Focusing on Quality in a Changing Health Care System” (1997), National Research Council.  “Crossing the Quality Chasm: A New Health System for the 21st Century” (2001) (ISBN 0309072808).