City Wide Quality and Safety Rounds: Thursday, May 11, 2017 @ 12-1PM

Topic: FIXING IT FOR GOOD: How human factors informed design can create a safer, more resilient health system

Speaker(s): Joseph A. Cafazzo, PhD PEng and Anjum Chagpar, MHSc PEng

Host Site: University Health Network: Toronto General Hospital, Peter Munk Building, 11th floor, Rm 190

Sites participating via OTN: C-QuIPS/Sickkids: 525 University Avenue, Rm 630; St Michael’s - Li Ka Shing Knowledge Institute, Rm 211; Sunnybrook: Bayview Campus - McLaughlin Auditorium, EG-61

OTN Webcast Link:

The rate of preventable adverse events has been stubbornly unchanged after many years of concerted effort to reduce harm in healthcare settings. Safety research and practice in healthcare continues to focus on measurement and cause of adverse events. Far less time has been focused on creating resilient solutions to the problem. This gap is likely why we’ve seen little progress in our safety efforts. There is however precedence in other industries on how to design safety critical systems that are resilient to human error, or that eliminate risk altogether. This presentation will describe how the healthcare settings must change in fundamental practice and governance to truly address the continued safety chasm.

The objectives of the session are:

I. To describe well established human-factors informed design methods that create more resilient mitigations to reduce and even eliminate harm.

II. To describe how safety practitioners can use these methods right now, and see results sooner, by diverting their time toward designing more resilient corrective actions, and focusing less on measurement and cause analysis.

III. To discuss how fundamental change is needed in healthcare practice and governance to reflect other safety critical industries.

Dr. Joseph Cafazzo co-founded Healthcare Human Factors @ UHN in 1994, growing to become largest group of its kind devoted to the application of human factors engineering to problems of healthcare delivery and patient safety. He is Associate Professor, University of Toronto, where he teaches and conducts research in the areas of human factors, clinical engineering, and health informatics. He is a recipient of the Career Scientist award by the Ontario Ministry of Health and Long Term Care and is Clinical Lead, Design and Engineering, of the Techna Institute at the University Health Network.

Anjum Chagpar is the cofounder and Managing Director of Healthcare Human Factors. Over the last 15 years, she has adapted and expanded the focus of her team to address broader patient safety challenges through the fusion of design disciplines with human factors engineering. Anjum holds degrees in Systems Design Engineering and Clinical Engineering from the Universities of Waterloo and Toronto respectively.