Raj teaches us human factors

A subtle advantage enjoyed by MedStar as it engages in its quality and safety transformation is the existence of its close affiliate, the National Center for Human Factors Engineering in Healthcare.  Another presenter at today's Quality and Safety Risk Management Retreat was Raj Ratwani, senior human factors scientist at NCHFEH.  Raj is a behavioral scientist with extensive experience in the airline industry and in the defense field.  I found--as did the attendees--much to learn from him.

Raj's presentation was an excellent primer on the types of errors that present themselves in complex systems.  Rather than knowledge-based errors (where people perform the wrong step as a result of a lack of knowledge) or rule-based errors (where people perform the wrong step because of misapplication of a rule), the predominant form of error in hospitals and other types of organizations is skill-based.  In this category, people perform the wrong step because of a slip or a lapse.

Raj stated, "No matter how capable we are, there is variability in our performance."  He noted that we all come to work with intentions to work at our highest level, but our work environment is full of interruptions, the workload is generally high, and fatigue and stress are real issues.

The task then is to design mechanisms that make it more difficult for people to make these kind of errors.  Instead of a "person approach" that focuses on the errors of individuals and blames them for failures of memory and attention, adopt a "systems approach" that focuses on the conditions under which individuals work and that builds defenses to avert errors or mitigate their effects.