Human Factors in Healthcare Dr Richa Ajitsaria Consultant Paediatrician The Hillingdon Hospitals NHS Foundation Trust

principle to enunciate as the very first requirement in a hospital – “It may seem a strange principle to enunciate as the very first requirement in a hospital – that it should do the sick no harm” Hippocratic oath – first do no harm. (Florence Nightingale: Notes on Hospitals,1859)

Hospital Mortality and Harm There is a one in 300 chance of accidental death through errors in care. (Institute of Medicine, 2000) More than one in ten people admitted to hospital are harmed unintentionally by its care. (Vincent et al. 2001) In 2000 an influential report entitled “to Err is Human: Building a Safer Health System” suggested that across the USA, somewhere between 44,000 – 98,000 deaths each year could be attribute to medical error A pilot study in the UK demonstrated that approximately 1 in 10 patients admitted to healthcare experienced an adverse event.

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Patient Safety 3,283 patients dead through preventable error, another 7,000 suffer severe harm Equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year…… …..in the UK! If you extrapolate these numbers – it’s the equivalent of 9 Boeing 737 aircraft being written off every year in the UK.

A mistake… Why did you make it? How did you discover you had made a mistake? What happened to you? What happened to the patient?

Situational Awareness Human Error Situational Awareness Limits of Performance Decision Making Communications Leadership Motivation Synergy Personality Morale Culture Ethos Stress/Sleep Workload Management Tech Knowledge So what are human factors? Human factors are the non-technical Human Factors Tech Skills

Humans make mistakes, no amount of checks and procedures will mitigate this fact. In fact the only way to completely remove human errors is to remove humans altogether! Not feasible, but we can improve the systems that allow the errors to take place. These articles are about an 18 year old teenager who had a chemotherapy drug, vincristine, injected intrathecally (into his spine) instead of intravenously. With fatal consequences. As you would expect, there were a whole host of factors that led to this…..

Two approaches to the problem of human fallibility: The person approach The systems approach Insert name of presentation on Master Slide

How do Accidents Happen? Organisation and processes -Pre-op, missing notes- latent Prior conditions – patient factors “Unsafe” acts – active failures Multiple Defences These multiple defences take the form of barriers, controls and defences which stand between the patient and the hazard. Lets think about a real error A patient with complex cardiac disease is admitted at midnight to the ward. She is on an unusual medication – clopidogrel (antiplatelet activity like aspirin) Seen and clerked by the reg, but mum didn’t have the doses, so drugs not written up. On the ward nurses ask SHO to write up drug chart Mum shows SHO the box Mistakenly writes 10 times the dose …2am, tired, hungry, unfamiliar drug, not in the BNFc… Dose given at 6am before pharmacist checks chart What were the factors that led to this?? What were the safety nets, how did they fail? Patient Safety Incident

Staff act as harm absorbers Adapted from REASON, 2005 Organisation Environment Workspace Factors within the healthcare system that could potentially lead to harm Task The ‘system’ Equipment People The basic premise of this model is that some organisational accidents could be thwarted at the last minute if front line healthcare staff have acquired some degree of error wisdom or foresight. Reason, amongst others, has recognised that health care staff who have direct contact with patients are the last line of defence and act as harm absorbers, that is they can catch and trap errors and problems before they lead to harm. Staff act as harm absorbers Staff Patients

Somebody read the sentence in the red triangle

The fact that we can misperceive situations despite the best of intentions is one of the main reasons that our decisions and actions can be flawed such that …

Human beings make “silly” mistakes Regardless of their experience, intelligence, motivation or vigilance, people make mistakes Detailed story + reason why. Eg same child admitted the next time on aspirin – discharge summary said dose 37.5 mg (75 mg tablets) – although clerking written 37.5 mg, the doctor has prescribed 75 mg… easy to see how this could have happened – busy, multitasking…

One definition of “human error” is “human nature” Error is the inevitable downside of having a brain!

Situations associated with an increased risk of error unfamiliarity with the task* inexperience* shortage of time inadequate checking poor procedures poor human equipment interface Vincent All common situations for inexperienced staff. * Especially if combined with lack of supervision

Individual factors that predispose to error limited memory capacity further reduced by: fatigue stress hunger illness language or cultural factors hazardous attitudes

Fatigue 24 hours of sleep deprivation has performance effects ~ blood alcohol content of 0.1% Dawson – Nature, 1997

Apply human factors thinking to your work environment (WHO) Avoid reliance on memory Make things visible Review and simplify processes Standardize common processes and procedures Routinely use checklists Decrease the reliance on vigilance

1. Avoid reliance on memory

2. Make things visible Single Point of Ward Information PSAG Board Patient status at a glance board PSAG Board Safety Briefings

3.Review and simplify processes Insert name of presentation on Master Slide

4. Standardise common processes and procedures Insert name of presentation on Master Slide

5. Routinely use checklists Insert name of presentation on Master Slide

6. Decrease the reliance on vigilance Insert name of presentation on Master Slide

The ‘three bucket’ model for assessing risky situations (Reason, 2004) 3 2 1 SELF CONTEXT TASK In the three bucket model of error likelihood - published in a paper in the journal Quality and Safety in Healthcare in 2004 - Reason states that the probability of unsafe acts is a function of the amount of bad stuff in three buckets: the self, the context and the task. The fuller each bucket is the more likely a healthcare professional is to commit an error or fail to recognise and respond to an unsafe situation before a patient is harmed. The self bucket relates to the current state of the individual involved, for example lack of knowledge, fatigue, negative life events. The second bucket relates to the nature of the context, that is distractions and interruptions, lack of time, lack of time, poor equipment etc. The third bucket represents the error potential of the task, that is how errors can occur at each individual step in a task. The error potential varies widely across the different steps of a task. Reason’s shift in thinking came about from evidence from various industries and healthcare examples of how people had demonstrated error wisdom and prevented bad situations from causing harm. Even when a system sets people up to fail there are many stories where pilots, other systems operators and healthcare professionals have rescued a bad situation at the last minute or prevented something bad from happening by foreseeing and controlling the risks. The fuller your buckets, the more likely something will go wrong, but your buckets are never empty.

Simulation Those who work together should train together. D. Cumin et al Standards for simulation in anaesthesia: creating confidence in the tools Br. J. Anaesth. (2010) 105(1): 45-51  Improving individual and team performance by working on clear communication : Effective communication with a feedback loop: Can someone attach the ECG Michael – can you attach the ECG Ok Michael can you attach the ECG ECG attached Team working, leadership (situational awareness), clear roles and followership (formula 1 pitstop) Hierarchy and raising concerns (PACE structure): Probe – I think the child may be cyanosed Alert – I am concerned - The child is deeply cyanosed – shall we start BVM Challenge – Dr Smith – you need to listen to me – we need to ventilate this child now Emergency – Dr Smith , move out of the way, the child is having a respiratory arrest I need to ventilate now.

Summary Health carers are human. We will make errors. Person approach vs systems approach Apply human factors thinking to your work environment Human factors = all factors that influence a person’s (or team’s) performance and behaviour Environmental Organisational Job factors Individual factors What influenced your behaviour at work this week?

Human Factors = All factors that influence a person’s (or team’s) performance and behaviour