parallel session 3.5 crossing boundaries to improve outcomes
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HUMAN FACTORSDr Rona Patey
Consultant Anaesthetist NHS GrampianHead of Division of Medical and Dental Education
University of Aberdeen
Who are we?
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11%1. Nursing
2. AHP
3. Medicine
4. Healthcare education – undergraduate
5. Healthcare education – postgraduate
6. Healthcare management
7. Human factors research
8. Human resources
9. Other
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Are you currently working on a human factors initiative?
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1. Yes – still in planning stage
2. Yes – within my team
3. Yes – across institutions
4. No – but I would like to
5. No
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Have you had previous education / training around human factors?
20%
20%
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20%1. No, not really thought about it
2. No, but would be keen to know more
3. Yes, a one off session
4. Yes, as part of a larger programme
5. Don’t know
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Things don’t always go right!
Human Factors
• ‘the scientific discipline concerned with the understanding of interactions between humans and other elements of the system, and the profession that applies theory, principles, data, and methods to design in order to optimise human well being and overall system performance’
International Ergonomics Association 2000
Human Factors
• Organisational / management– Safety culture– Management
leadership– Communication
• Work environment– Work environment and
hazards (ergonomics
• Workgroup(s) / Team (s)– Team structures / processes– Team leadership
• Individual worker– Cognitive
• Situation awareness• Decision making
– Personal resources• Management of stress• Management of fatigue
Exercise
• A picture will appear on the screen for around 15 seconds
• Examine the picture closely and look for a change
• Raise your hand when you spot a change
Safety
• Error is inevitable and ubiquitous!– Humans are fallible
Helmreich 1996
• Critical incident students reveal that around 80% of underlying issues relate to human factors– Frequently avoidable
Admitted with UTI
On 5 Medications
Wrist fracture six months ago
Mobilises with a frame
Patient Condition
Drug ChartMedical Records Ward
Environment Workforce &Communication
Lack of staff training
The latent failure model of complex system failuremodified from James Reason, 1997
AccidentTrajectory
Safety
• Systems should be designed with ‘defenses in depth’
– Organisational, management, equipment design, workspace layout
– Should provide the human in the systems with the necessary knowledge and skills to deal with threats in their environment / to act as hero
• technical skills are not enough!
Reason 1997
Lessons from other industries
• Human factors & safety integrated to the core curriculum– undergraduate– continuing professional development
• Compulsory adverse event reporting with investigation and learning (organisation and industry)
• Briefing and debriefing part of the culture
Lessons from other industries
15/1/2009
Flight 1549
Routine flight from New York to Charlottesville
What about healthcare?
ANTS System
Example behaviours for poor practice
Example behaviours for good practice
Categories Elements
Task Planning and preparing
Management Prioritising
Providing and maintaining standards Identifying and utilising resources
Team Co-ordinating activities with team members
Working Exchanging information
Using authority and assertiveness
Assessing capabilities Supporting others
Situation Gathering informationAwareness Recognising and understanding
Anticipating
Decision Identifying optionsMaking Balancing risks and selecting options
Re-evaluating
Reduces level of monitoring because of distractions Responds to individual cues without confirmation Does not alter physical layout of workspace to improve data visibility Does not ask questions to orient self to situation during hand-over
Confirms roles and responsibilities of team members Discusses case with surgeons or colleagues Considers requirements of others before acting Co-operates with others to achieve goals
Taking a human factors approachA healthcare example?
Human Factors
http://www.chfg.org/
‘about making it easier to do the right job’
Martin Bromiley
Human factors training should be incorporated as a core skill?
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20%1. Strongly Agree
2. Agree
3. Neutral
4. Disagree
5. Strongly Disagree
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