APPLYING HUMAN FACTORS METHODS AND APPROACHES Dr Jane Carthey, Human Factors and Patient Safety Consultant www.janecarthey.com Email:jane@janecarthey.com

Human Factors definition Human factors encompasses all of those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors and individual characteristics which influence behaviour at work. Clinical Human Factors Group. 2009

Inattentional blindness 83% radiologists did not see the gorilla Gorilla = 48X size of nodule on a CT scan Don’t see what you are not expecting to see Drew, Vo and Wolfe (2012) Inattentional blindness is important in the context of healthcare because it means healthcare professionals sometimes only see what they are expecting to see. For example, Drew, Vo and Wolfe (2012) showed radiologists CT scans and asked them to look for cancer nodules on the CT scans. 83% of radiologists did not see the image of the gorilla on the left lobe of the CT scan, even though it was around 48 times the size of an average cancer nodule. Some of the group members may not be able to see the image of the gorilla on the slide. It is helpful if the facilitator walks to the screen and points out the image (in the left hand lobe).

Last task step (Fischhoff et al Last task step (Fischhoff et al. 1978) & involuntary automaticity (Toft and Mascie, 2005)

Organisational, environmental and job factors Balance between efficiency and safety goals Procurement (standardisation, introduction of new IT systems/devices) Design of equipment Culture (professional silos and conflicts) Workload

ENVIRONMENTAL AND DESIGN FACTORS

DESIGN IN HEALTHCARE

PROCUREMENT, IT, FINANCE ETC…

FORCING FUNCTIONS

Some human factors tools and approaches Eliciting information from people involved and witnesses Using change analysis to evaluate the drift between ‘the world as imagined’ versus ‘the reality’ Contributory factors analysis A human factors perspective on the relative strength of solutions

Witness memory degradation

Cognitive interviewing (Geiselman, Fisher 1984) Tell me EVERYTHING you can remember Tell me what happened from the end of the day and work back wards in time from there Tell me what was happening if you were standing in ….. shoes, if you were the patient….. Tell me about the sounds you can hear. GIVES THE PERSON BEING INTERVIEWED CONTROL SO THAT THEY CAN RETRIEVE MEMORIES AT THEIR OWN PACE

Systemic Migration to Boundaries (Amalberti et al., 2006) Driving 75 mph- the ‘Illegal-normal’ space The posted speed limit is 70 mph- the ‘legal’ space INDIVIDUAL BENEFITS Belief Systems. Life Pressures Driving 85+ mph – the ‘illegal-illegal’ space (for almost all of us!) Perceived vulnerability VERY UNSAFE SPACE This slide builds and is a good example of how we all violate the rules nearly every day ACCIDENT PERFORMANCE Content © atrainability 2010 & JC Consulting

Identifying what happened: CHANGE ANALYSIS Describe the normal procedure. Compare this with the chronology of the incident. List the changes. Did the changes contribute to the incident? These changes to the normal are the ‘what’ happened Analyse - Carefully assess the differences and identify possible underlying causes. Describe how these affected the event. Did each difference or change explain the result?

CHANGE ANALYSIS Normal / Accepted Procedure   Normal / Accepted Procedure (as defined by Trust policies and procedures, national guidance (e.g. NICE, NPSA) Actual Procedure at time of Incident Was there a change (Y/N) Did the change contribute to the incident? If yes, describe the CDP/SDP that contributed to the incident The Trust Hospital at Night policy states that acutely medically unwell patients who are at risk of sudden deterioration overnight should be added to the Sick List database and handed over to the H@N team at H@N handover Patient X not added to the Sick List database by ward staff. Consequently Patient X was not discussed at H@N handover and the night duty medical registrar and the PERT team were unaware of the patient’s condition Yes Care delivery problem: Communication of sick patient via the sick list database omitted by ward staff Service delivery problem: H@N Policy is unclear about which member of the ward staff is responsible for adding a sick patient onto the Sick List database Service delivery problem: The Sick List database is not stored in a drive that ward nurses can access meaning they cannot follow the H@N Policy’s process for adding patients at risk of deterioration onto the Sick List database. Service delivery problem: H@N Policy not disseminated to ward nurses when it was launched resulting in a lack of clarity about the escalation to the Sick List process

Cafazzo JA and St-Cyr O. From Discovery to Design Healthcare Quarterly (2012): 24-29.

Humanity of the lead investigator Detached, analytical task Evidence-based focus What about the second victim(s)?

Take home messages Human factors issues can prevent you carrying out a thorough and fair investigation We need to widen the lens of the investigation process to ensure a thorough understanding of human factors issues is captured