Erring on the Side of Human Factors for Patient Safety

Institute of Medicine Report

On December 7, 1999, the Institute of Medicine (IOM) dropped a bomb during what would have been a quiet congressional recess. The "bomb" was a report entitled "To Err is Human: Building a Safer Health System," identifying medical error as the third leading cause of death in the United States. Fortunately, beyond identifying the problem, the report also made several recommendations to begin addressing the problem. Those recommendations included the creation of a Center for Patient Safety to be housed within the Agency for Health Research Quality (formally, the Agency for Health Care Policy Research) and recommendations to develop both voluntary and mandatory reporting systems to help identify the context in which errors occur.

The report received wide attention from both the Clinton administration and the popular press, and Congress soon followed suit. Sen. Arlen Specter (R-PA) initiated hearings in his Appropriations Subcommittee, which provides federal funding for a variety of public health agencies. Sen. Jim Jeffords (R-VT) began a series of hearings in his Health Education Labor and Pensions Committee, which provides legislative authority for public health programs.

Efforts to Bring Human Factors Expertise to the Table

APA, the Federation of Behavioral, Psychological, and Cognitive Sciences, and the Human Factors and Ergonomics Society (HFES) began a concerted lobbying effort to make sure that the interests and experience of human factors psychologists were brought to bear on the legislative process. As a result, we were invited to participate in congressional staff briefings, and to comment on Sen. Specter's draft legislation "The Medical Error Reduction Act of 2000." We suggested several changes to expand the scope of the bill in the interest of building a culture of safety. In addition, APA and the Federation arranged for experts in the field of patient safety to conduct team briefings for Senate Labor Committee staff and House Commerce Committee staff during the second week of February.

Complexity of Medical Error and Injury Issues

Experts believe that any legislative action should aim to reduce the number of medical errors, and the resulting deaths and injuries, but that success depends on understanding the complex nature of medical error. Measures not designed with respect for that complexity risk being ineffective or even injurious themselves. Medical error is usually the result of a confluence of circumstances rather than simply one person making a mistake, so reducing medical error and injury cannot be accomplished simply by identifying and punishing individuals who have made errors. Instead, most experts believe that reduction depends on addressing error systemically. That is, it depends on understanding the relationship between proximal and distal causes of error and altering the causal stream, so that errors are not facilitated. Reduction of error and injury also depend on understanding success, since medical-setting studies show that far more accidents are waiting to happen than actually happen.

Given the level of complexity in understanding medical error and injury issues, the task for psychologists entering the debate is to highlight several key points for Congress. First, a convincing case must be made for funding sophisticated data collection and analysis to better understand the nature of error and success in medical settings, and for applying this knowledge to improve medical treatment. As always, there is the danger that Congress may respond to pressure from many constituencies by instituting reporting and investigative procedures that are not empirically supported. Second, any program designed to combat error and injury must obtain cooperation of the stakeholders -- those within the medical system -- in order to be effective. Finally, expertise from a variety of scientific and technical disciplines must be incorporated at all stages of program design and implementation.

Clearly, error in medicine (as in any complex system) involves understanding how people perform, how people think, how people communicate with one another, and how people interact with technology in complex organizational systems. So a systems approach to understanding both safety and error involves multiple domains within scientific psychology, and we look forward to bringing that perspective to light in developing a useful response to the IOM report. If you haven't already reviewed the National Patient Safety Foundation report entitled "A Tale of Two Stories: Contrasting Views of Patient Safety", you can read it online. [View the report.]

Four Psychologists Brief Congressional Staff

In February, APA and the Federation of Behavioral, Psychological, and Cognitive Sciences brought four distinguished psychologists to Washington to brief congressional staffers on crucial issues in the medical error and injury debate.

Marilyn Sue Bogner, PhD, is President and Chief Scientist of the Institute for the Study of Medical Error. In that capacity, she directs and conducts research using her systems approach to identify factors that contribute to error. She was previously employed by U.S. government agencies, where she addressed the contribution of medical device design to user error, examined user error issues in military equipment, and studied crosscutting issues in health services.

David Kobus, PhD, is the Director of Medical Systems at Pacific Science and Engineering, Inc., and Chair-elect of the Medical Systems Technical Group of the Human Factors & Ergonomic Society. Kobus has been involved in human performance research and project management for over 16 years. His work in medical systems error analysis currently identifies, categorizes, and quantifies errors in health care delivery.

John Senders, PhD, is Principal Scientific Consultant to the Institute for Safe Medication Practice. He has organized conferences on the nature and source of human error and co-authored a book entitled Human Error, published in 1991. He has worked extensively with pharmacy and nursing professionals on issues related to error and injury and has keen insight on practical issues related to error reporting and liability.

David Woods, PhD, is Professor in the Institute for Ergonomics at the Ohio State University. In addition to his work on human factors in aviation, space operations, and nuclear power, Woods has been active in research that applies human factors to medicine for the last 11 years. He is on the Executive Committee and Board of the National Patient Safety Foundation and co-wrote the Foundation's 1998 report, "A Tale of Two Stories: Contrasting Views of Patient Safety."

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