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

3. 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

4. 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.

5. The Human Factors Approach Helps us understand why things don’t work right ….and find solutions!

6. 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)

7. The task / technology

11. Human Factors Solutions Ergonomics Improved Design Improved labelling / packaging

12. The individual

13. Why did Elaine die? Failure to intubate Failure to oxygenate

14. Human Factors in Safety Accident Causation Technical Factors Human Factors Organisational / Safety Culture Operator Behaviour =+ (30-20%) (70-80%)

15. Human Factors in Safety Accident Causation Technical Factors Human Factors Organisational / Safety Culture Operator Behaviour =+ (30-20%) (70-80%)

16. 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

17. 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

18. Non-technical skills Avoid problems Identify & treat incidents Manage emergencies

19. 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)

20. Human Factors Solutions Identifying NTS in healthcare

21. Situation Awareness Decision Making Task Management Team Working Gathering Information Recognising & Understanding Anticipating Anaesthetists’ Non-Technical Skills Skill Categories Skill Elements Behavioural Markers Good: keeps ahead of the situation by giving fluids / drugs Poor: is caught unaware by surgical actions

22. 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

23. The organisation

24. 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

25. Forcing functions Redundancy Simplification Standardization Automation and computerisation Improve hand-overs Improve access to information Decrease reliance on memory Human Factors Solutions

26. Effective Systems From Reason Error stopped, no Accident occurs. Develop systems and processes to prevent errors/accidents from happening and that can manage them when/if they occur.

27. 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.

28. 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

29. 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?

30.  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 Vented cap on Y-port. Air bubble in line

31.  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 Vented cap on Y-port. Air bubble in line

32. 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

33. 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

34. 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)

36. n.maran@nhs.net www.chfg.org www.institute.nhs.uk www.iprc.abdn.ac.uk/ants www.scsc.scot.nhs.uk