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Human Factors in Healthcare. Dr Nikki Maran Consultant Anaesthetist, Royal Infirmary of Edinburgh Director, Scottish Clinical Simulation Centre, Forth Valley Royal Hospital, Larbert. Human Factors.

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human factors in healthcare

Human Factors in Healthcare

Dr Nikki Maran

Consultant Anaesthetist, Royal Infirmary of Edinburgh

Director, Scottish Clinical Simulation Centre,

Forth Valley Royal Hospital, Larbert

human factors
Human Factors...

‘...refers to environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work (in a way that can affect health and safety.)’

Health and Safety Executive (1999)

Reducing Error and Influencing Behaviour

basic tenets of human factors
Basic Tenets of Human Factors
  • Everyone makes mistakes
  • Errors are often beyond our conscious control

Systems that depend on perfect human performance are fatally flawed.

the human factors approach
The Human Factors Approach

Helps us understand why things don’t work right ….and find solutions!

the human factors approach1
The Human Factors Approach

Helps us understand why things don’t work right ….and find solutions!

  • The task / technology (hardware / software)
  • The individual (liveware)
  • The organisation (environment)
human factors solutions
Human Factors Solutions
  • Ergonomics
  • Improved Design
  • Improved labelling / packaging
why did elaine die
Why did Elaine die?
  • Failure to intubate
  • Failure to oxygenate
slide14

Human Factors in Safety

Technical

Factors

(30-20%)

Accident

Causation

Human

Factors

Organisational /

Safety

Culture

Operator

Behaviour

(70-80%)

=

+

slide15

Human Factors in Safety

Technical

Factors

(30-20%)

Accident

Causation

Human

Factors

Organisational /

Safety

Culture

Operator

Behaviour

(70-80%)

=

+

why did elaine die1
Why did Elaine die?
  • Failure to intubate
  • Failure to oxygenate
  • Failure of leadership
  • Breakdown in decision making
  • Communication dried up
  • Lack of assertiveness
  • Loss of awareness
why did elaine die2
Why did Elaine die?
  • Failure to intubate
  • Failure to oxygenate
  • Failure of leadership
  • Breakdown in decision making
  • Communication dried up
  • Lack of assertiveness
  • Loss of awareness
non technical skills
Non-technical skills

Manage emergencies

Identify & treat

incidents

Avoid problems

health committee patient safety report for nhs england july 2009
Health Committee patient safety report for NHS England (July, 2009)

“The NHS lags unacceptably behind

other safety-critical industries, such

as aviation, in recognising

the importance of effective team working and other non-technical skills.” (p5)

“There are serious deficiencies in the

undergraduate medical curriculum ..

which are detrimental to patient safety,

in respect of training in ……non-technical skills....” (p6)

human factors solutions1
Human Factors Solutions

Identifying NTS in healthcare

slide21

Anaesthetists’ Non-Technical Skills

Situation Awareness

Decision Making

Task Management

Team Working

Skill Categories

Gathering Information

Skill Elements

Recognising & Understanding

Anticipating

Behavioural Markers

Good: keeps ahead of the situation by giving fluids / drugs

Poor: is caught unaware by surgical actions

human factors solutions2
Human Factors Solutions

“The NHS must be able to provide the sort of simulation training that would make a difference to patients like Elaine Bromiley.”

  • CMO Annual Report 2008
systems error
Everyday Examples

Can put petrol in diesel tank

Cars lurch forward when started in gear

Healthcare Examples

Patients admitted to wrong wards due to bed shortages

Legibility of handwritten orders (prescriptions)

Allowing 100 mg to be administered if 10 mg was ordered

Systems Error
human factors solutions3
Human Factors Solutions
  • Forcing functions
  • Redundancy
  • Simplification
  • Standardization
  • Automation and computerisation
  • Improve hand-overs
  • Improve access to information
  • Decrease reliance on memory
effective systems
Effective Systems

Error stopped,

no Accident occurs.

From Reason

Develop systems and processes to prevent

errors/accidents from happening and that

can manage them when/if they occur.

moving systems towards safety
Moving Systems Towards Safety
  • An unreported error/vulnerability cannot be investigated

If we don’t know about it, we can’t investigate it and we can’t fix it.

barriers to reporting
Barriers to Reporting
  • Punitive culture
  • Don’t know what to report
  • Time
  • Cumbersome reporting systems
  • Poor feed-back of reported events/actions
  • Belief that “reporting doesn’t make any difference”
  • Belief that “work-arounds” are the normal way of doing business
learning from adverse events
Learning from adverse events
  • Identifying ‘near misses’
    • An error that occurs somewhere in the process, but does not reach the patient
    • An error that has not turned into an accident
  • Could the recurrence of this event put another patient at risk in the future?
slide30

Air bubble in line

Vented cap on Y-port.

  • Incidents have been reported of air sucked in to the line from Y-ports of extension sets used with syringe pumps.
  • Risk: air bubbles being pumped into the patient.
  • The incidents have occurred with Wescott extension sets fitted with Y-ports.
  • They have arisen since Wescott changed from a non-vented to a vented cap on the Y-port.
          • Potential problem recognised March 2010
slide31

Air bubble in line

Vented cap on Y-port.

  • Incidents have been reported of air sucked in to the line from Y-ports of extension sets used with syringe pumps.
  • Risk: air bubbles being pumped into the patient.
  • The incidents have occurred with Wescott extension sets fitted with Y-ports.
  • They have arisen since Wescott changed from a non-vented to a vented cap on the Y-port.
          • Potential problem recognised March 2010
  • July 2010
  • PCA attached to central venous catheter
  • Patient on CVVH
  • Air entrained as above
  • Massive air embolus results in dense hemiplegia
learning from adverse events1
Learning from adverse events
  • Identifying ‘near misses’
    • An error that occurs somewhere in the process, but does not reach the patient
    • An error that has not turned into an accident
  • Could the recurrence of this event put another patient at risk in the future?
  • If so, DO SOMETHING TO RECTIFY
changing the culture
Changing the Culture
  • Eliminate “shame and blame” mentality from healthcare
  • Accept that our clinical staff will make errors and build systems to support their work
  • Foster a culture of safety where people can speak up
  • Organizational learning from errors and near-misses
the human factors approach2
The Human Factors Approach

Helps us understand why things don’t work right ….and find solutions!

  • The task / technology (hardware / software)
  • The individual (liveware)
  • The organisation (environment)
slide36

n.maran@nhs.net

www.chfg.org

www.institute.nhs.uk

www.iprc.abdn.ac.uk/ants

www.scsc.scot.nhs.uk