Why PEXiS?
The GAPS Center compared results of analysis by human factors experts
in a consecutive series of adverse events versus the analysis of the same
cases by medical experts (risk managers) and found that human factors experts
identified many more contributors to the failures, and that the responses
and solutions from the analysis often drove the appropriate "fix".
These contributors often represent the common thread underlying adverse
events. Once these patterns are identified, healthcare organizations can
target these vulnerable areas as high priority areas for system redesign.
Experts in human factors also saw many patterns across the series of cases
that had not been identified at all. From this analysis, the GAPS Center
developed the PEXiS modular curriculum to train medical personnel to be
experts in the analysis of adverse events using human performance theory.
The modules are:
- PEXiS 1 Behind the Label 'Human Error'
- PEXiS 2 Escape from Data Overload
- PEXiS 3 Process tracing: Analyzing Human Performance in Context
- PEXiS 4 Avoiding Organizational Contributors to Complexity
People at work under time, production and personnel constraints perform in predictable ways across all industries to manage their workload and complete their tasks.
Historically, people do predictable things. The discipline of human factors recognizes predictable human failures and incorporates this knowledge into ideas of system redesign in healthcare.
When accidents occur, response has been to:
- BLAME
- TRAIN
- CREATE NEW POLICIES AND PROCEDURES
Yet accidents persist. PEXiS teaches the human aspects of human error. If we recognize predictable human failure patterns, system redesign can be more effective.