National Patient Safety Agency Colum Menzies Lowe Head of Design

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National Patient Safety AgencyColum Menzies
LoweHead of Design Human Factors
www.npsa.nhs.uk
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only two things are infinite, the universe and
human stupidity, and Im not sure about the former
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Florence Nightingale

• the very first requirement
• in a Hospital is that it
• should do the sick no harm
• Notes on Hospitals 1863

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Is There a Problem?

• In acute care
• 11 of all acute admissions suffer an incident
• 8 of those incidents prove fatal
• 50 of incidents thought to be avoidable
• Vincent et al
• The NHS treats 9million patients a year

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But we all make mistakes!
If we accept to err is human how do we solve the
patient safety issue?
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What to do?

• Know there is a problem

• a problem beyond the conventionally attributable
  user error

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How would you operate these doors?
Push or pull? left side or right? How did you
know?
A
C
B
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Which dial turns on the burner?
Natural Mappings
Stove A
Stove B
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Almus Pharmaceuticals
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What to do?

• Know there is a problem
• Change the system

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What to do?

• Every system is perfectly designed to achieve
  exactly the results it gets
• Donald Berwick
• President of the Institute of Healthcare
  Improvement

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Reasons Swiss Cheese model
some holes due to active failures
other holes due to latent conditions
defences, barriers and safeguards
James Reason 1997
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Who gets the blame?
products
peripherals
policy
procedure
patients
providers
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The Blame Culture

• The dual myths of
• Perfection
• Physicians are expected to function without
  error, and believe there is no error without
  negligence
• Punishment
• Meted out through the malpractice tort
  litigation system in an attempt to pressurise
  clinicians towards perfection
• All humans err frequently and systems that rely
  on error-free performance are doomed to fail
• Lucian Leape, Error in Medicine, JAMA, 1994

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What to do?

• Know there is a problem
• Change the system
• Design for Patient Safety

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Design and the NHS

• The NHS is seriously out of step with modern
  thinking and practice with regards to design .
  And also fails to understand what design thinking
  can bring to an organisation . A direct
  consequence of this has been a significant
  incidence of avoidable risk and error
• Department of Health Design Council, Design
  for Patient Safety

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Pillar or post boxes
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Public call offices
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The Routemaster bus
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British road signs
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The London Tube Map
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The Renkioi Hospital Isambard Kingdom Brunel
Just a sober exercise of common sense
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Building a Safer NHS for Patients recommends .

• seeking input from the world of design to
  identify new opportunities for improved safety
• Department of Health

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The Design Wheel
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Design is a .

• Process
• All design processes are creative, inclusive and
  iterative and the quality of their management is
  potentially the major contributing factor to
  their successful outcome

Problem solving In the private sector most
problems revolve around the acquisition of
profits, in healthcare they are primarily
concerned with improving patient outcomes safety
User centred If there is no user it is not
design, the whole concept of design is to create
solutions around user needs
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Design out the problem

• Usability
• Accident proofing
• Standardisation
• Systemic awareness

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Design out the problem

• Usability
• Physical cognitive ergonomics
• Remove device/label/environment/process induced
  use-error

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Design out the problem

• Usability
• Accident proof
• Stop
• Spot
• Mitigate

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Forcing functions
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Design out the problem

• Usability
• Accident proofing
• Standardisation
• Not commoditisation
• User/device interface
• Safety critical features

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Infusion Devices

• 800 infusion device related incidents annually
• 53 device found to be working to specification
• Source Medicines and Healthcare Products
  Regulatory Agency

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Medical Device DirectiveGeneral Requirements
Devices must be designed and manufactured in such
a way as to remove or minimise as far as possible
the risk of injury, in connection with their
physical features, including the volume/pressure
ratio, dimensions and where appropriate ergonomic
features
inherently safe design and construction
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Design out the problem

• Usability
• Accident proofing
• Standardisation
• Systemic awareness
• Elements entering the system are designed to
  operate safely within the system and with full
  knowledge of the system

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Diathermy and the operating room
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Design out the problem

• Human error
• or
• Design induced use-error

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The Financial Argument

• Patient safety incidents cost the British
  taxpayer 3billion pounds a year
• A detailed study by Berry et al in the USA, The
  Business Case for Better Buildings, found that
  the cost of building a better, safer, less
  wasteful hospital was an additional 5, but paid
  back in a little over 12 months

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Lifetime Costs of an Acute Hospital

• cost in-use to client 50-200

cost of maintenance 5
cost of building 1

cost of design 0.1

PFI
Devised by John Cole, NI Health Estates
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St Elbaf, Hapshire

• Design costs 15-30million
• Build costs 300million
• Maintenance costs 1.5billion
• In-use costs 30billion
• Patient safety incidents a year 3,000
• Accidental deaths a year 240
• Annual clinical cost 7million
• Secondary infections 3,000
• Death from infections 17 (1994-95)
• Clinical cost of infections 3.5million (1994-5)
• Litigation costs 3.5million

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St Josephs, West Bend, Wisconsin
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St Josephs, West Bend, Wisconsin

• Initiators and Motivators
• Processes and Tools
• People and Practices
• Assessing Results

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St Josephs, West Bend, Wisconsin
the data and anecdotes about medical errors are
powerful and simply staggering and could not be
ignored John Reiling President and CEO so how
can we improve patient safety and quality by
design? Barbara Knutzen COO
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Evidence Based Design

• An Inclusive Process
• Focus on Precarious Events
• Address Latent Conditions

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Evidence Based Design

• An Inclusive Process
• Patients/families/staff involved in the design
  process
• Design for the vulnerable patient
• Equipment planning and mock-ups on day 1
• Human Factors risk assessment at each stage
• Establish a checklist for current/future needs

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Evidence Based Design

• Focus on Precarious Events
• Operative/post operative complications/infections
• Events relating to medication error
• Deaths of patients in restraints
• Inpatient suicides
• Transfusion related events
• Correct tube, correct connector, correct hole
• Patient falls
• Deaths related to wrong site surgery
• MRI hazards
• John Reiling, President, West Bend Clinic

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Evidence Based Design

• Address Latent Conditions
• Single bed rooms in almost all situations
• Reduce noise levels
• Reduce patient stress
• Develop effective wayfinding systems
• Improve ventilation
• Access to natural lighting and full spectrum
  lighting
• Reduce staff walking and fatigue
• Accessibility to patient information
• Ulrich Zimring

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The Healing Environment

• Access to direct sunlight
• Positive distraction (art, television, web, etc)
• Social/family interaction
• Views of nature
• Control over immediate environment
• Pleasant, quality surroundings
• Dignity and respect
• Privacy
• Quiet and calm

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for 100 single patient rooms

• Healthcare Associated Infection
• Slips, trips and falls
• Staff to patient communication
• Patient confidentiality and privacy
• Family support
• Patient stress (noise and sleep deprivation)
• Reduction in patient transfers
• Bed availability
• Patient satisfaction

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against 100 single patient rooms

• Increased nursing resource required
• Reduced staff to patient observation
• Reduced social interaction
• Isolation
• Space hungry
• Cost

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Patient Safety Indicators

• Infection rates
• Slips, trips and falls
• Equipment errors
• Medication error

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Latent Condition Indicators

• Malnutrition
• Patient transfers
• Staff to patient care contact time
• Staff culture behaviour
• Length of stay
• Re-admission rates
• Complaints litigation
• Patient satisfaction rates

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National Patient Safety AgencyColum Menzies
LoweHead of Design Human Factors
www.npsa.nhs.uk