Human factors can be defined as
Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings. (Catchpole 2010)
Essentially human factors consider how different factors relating to the individual, environment and culture can interact and influence performance.
The NHS provides care to tens of thousands of people every day. The dedicated NHS staff typically provide excellent care but unfortunately errors occur. An example of how human factors can lead to tragedy within healthcare is outlined below in the video.
Take a few moments to watch the video and consider the following:
- Was there a structured approach to the emergency?
- What was the aim once difficulties were encountered?
- Who was in charge?
- How did the team function?
The Elaine Bromiley Case Video. Simpact Pty Ltd, 2014. Reproduced under Creative Commons Attribution Non-Commercial No Derivatives License. © Copyright Simpact Pty Ltd 2014.
This tragic event occurred despite care being provided by a highly skilled and experienced team. Nobody is immune to human factors and everyone has a responsibility to consider how their own performance could be affected by the issues raised by the case of Elaine Bromley.
There are number of issues to consider from the video:
- Failure to plan for failure (no plan B)- not preoxygenated, emergency drugs not prepared
- Task fixation – goal to intubate patient rather than of oxygenate (loss of awareness)
- Structured approach not followed – same failed technique repeated again and again
- Who was in charge? – can’t lead and do at same time, therefore no effective leader
- Poor communication between team members – not vocalised this is a can’t intubate, can’t ventilate scenario
- Lack of assertiveness/hierarchical culture – nurses recognised “can’t intubate, can’t ventilate scenario” but didn’t speak up.
The issues highlighted above are discussed in more detail in the following video:
Just a Routine Operation Video. Clinical Human Factors Group (CHFG). Reproduced with kind permission of CHFG.
Understanding Human Error
Humans make mistakes!
All humans make mistakes, we get distracted, we are susceptible to fatigue and performance can vary depending on the time of day, length of shift and if we are hungry, angry or emotional. To exacerbate the issue we live and work in complex social structures that are often hierarchical.
Traditionally in healthcare fallible human beings are then tasked with providing a skilled service in a high stress and high workload health service with very little defence against mistakes beyond their own vigilance.
This idea is probably best known through the “Swiss cheese” model of organisational accidents (Reason 1990). The idea is that within healthcare there are a number of defences against error. These defences are not perfect and have little holes in known as “latent conditions”. The size of these holes depends upon the design of the defences. Poorly designed defences increase the size of the holes and place a greater burden on the frontline staff to avoid errors through vigilance alone.
To illustrate the Swiss Cheese Model and Latent conditions lets consider the fictional case below. Try and identify the latent conditions in this case:
A 5-month-old child is brought in by ambulance late at night to a district general hospital. Overnight a junior doctor staffs the emergency department with senior cover available from home. It is one week after changeover and this is the junior doctor’s first paediatric placement.
The child is brought in cardiac arrest with CPR on-going.
The department has pre-written wet-flag cards for resuscitation. The nursing student is asked to copy out the correct card for the child.
The nursing student accidentally picks up the 5 year old card rather than the 5-month card. The ages are written using shorthand with 5 meaning 5 years and 5/12 meaning 5 months.
The child is resuscitated using the wrong weight and drug doses and dies.
Reducing Human Error
To reduce human error there needs to be a culture within healthcare that allows staff to identify latent conditions and report them without fear of blame and safe in the knowledge that learning will occur and things will improve. Elements of that safety culture are explored in the table below.
The same team who made the initial simulation video have made a second video showing how simple changes could have resulted in a different outcome in the case. Hopefully this highlights how human factors can be mitigated if the systems are in place to reduce the reliance of healthcare on the vigilance and performance of individuals.
What If? Teamwork in Emergency Airway Management Video. Simpact Pty Ltd, 2014. Reproduced under Creative Commons Attribution Non-Commercial No Derivatives License. © Copyright Simpact Pty Ltd 2014.
Managing the paediatric airway in a critically ill child can be especially difficult and there are a number of practical steps that can be used to minimise the risk to the child these include:
• Separating airway management from team leading and allowing one doctor to have an overview of the patient
• Clear communication; ask for specific things from assigned people and ask them to confirm when that is done
• Build in an opportunity for those around you to question and challenge
• Have a plan (ideally a checklist)
• Surgical airway is not failure (just plan D) don’t be afraid to mark the site of surgical airway insertion prior to intubation attempts
During the course there will be opportunity to practice airway management in a number of challenging scenarios. We encourage all participants to consider address human factors in the simulations.
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