1. APPLYING HUMAN FACTORS METHODS AND APPROACHES
Dr Jane Carthey, Human Factors and Patient Safety Consultant

2. 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

3. 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).

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

5. 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

6. ENVIRONMENTAL AND DESIGN FACTORS

7. DESIGN IN HEALTHCARE

8. PROCUREMENT, IT, FINANCE ETC…

9. FORCING FUNCTIONS

10. 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

11. Witness memory degradation

12. 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

13. 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

14. 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?

15. 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 team at handover
Patient X not added to the Sick List database by ward staff. Consequently Patient X was not discussed at 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: 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 Policy’s process for adding patients at risk of deterioration onto the Sick List database.
Service delivery problem:
Policy not disseminated to ward nurses when it was launched resulting in a lack of clarity about the escalation to the Sick List process

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

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

19. 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