1. PST Human Factors Jan Shaw Manchester Royal Infirmary CMFT

2. PST Human Factors  Human factors theory focuses on a range of topics associated with human abilities, behaviours and limitations in the context of workplace safety  Theory operates on 2 levels

3. PST Human Factors & Systems  The theory can be applied to influence the design of systems, tasks, equipment, workplace layout, job planning etc to make allowances for human capability in complex working environments

4. PST Human Factors & Individuals At an individual level, human factors theory describes the non- technical skills which complement individual technical skills to facilitate safe and efficient performance of tasks

5. PST Non-technical Skills Effective communication Team working Leadership Decision making Situation awareness Stress management Cognitive, social and personal skills:

6. PST Error Chains ADVERSE EVENT Latent Failures Active Failures Unsafe Situation Final Error (Point Of No Return) Poor Situation Awareness Human Errors System Errors Happen- stance Catalyst Events

7. PST Swiss Cheese Model

8. PST Swiss Cheese Healthcare Model

9. PST

10. PST System design & management Equipment Equipment shortages Inadequate maintenance of equipment Incompatible goals (e.g. conflict between financial and clinical need)

11. PST Training Inexperienced personnel working unsupervised No scheduled training sessions for updating staff in the use of new techniques / equipment Inadequate knowledge or experience / incomplete training System design & management

12. PST Communication Inadequate systems of communication Loss of documentation (e.g. previous patient records not available) Highly mobile working arrangements leading to difficulties in communication System design & management

13. PST Situation Awareness Organisational & professional cultures which induce or tolerate unsafe practices No requirement at organisational level to undertake formalised checking procedures Heavy personal workloads / lack of time to undertake thorough assessments Reluctance to undertake a formal analysis of adverse events / learn from errors System design & management

14. PST Theatre Team

15. PST Working in Silos AnaesthesiaSurgeryNursing

16. PST Working in Silos WardsTheatresIntensive Care

17. PST Individual & Team Non-technical Skills Communication & Teamworking Incomplete or inadequate briefing and handovers / poor or non-existent debriefing Poor or dysfunctional communication - especially between specialities Failure to follow advice from a senior colleague Failure to formulate back-up plans and discuss with the team members Lack of clarity in team structures (e.g. in a multidisciplinary team, who is in charge?)

18. PST Individual & Team Non-technical Skills Decision-making Failure to undertake appropriate preoperative investigations Failure to use available equipment (e.g. capnography) Attempts to use unfamiliar equipment in an emergency situation Casual attitude to risk / overconfidence

19. PST Individual & Team Non-technical Skills Leadership & Task Management Peer tolerance of poor standards Failure to take and document a comprehensive history / perform an airway assessment Failure to request previous patient records Inadequate checking procedures Failure to cope with stressful environment / interruptive workplace

20. PST Individual & Team Non-technical Skills Situation Awareness Fixation errors, resulting in a failure to recognise and abort a plan which is not working, and move to another potential solution Wrong interpretation of clinical findings / test results Frequent / last-minute changes of plan

21. PST Panel Assessment Poor judgement -Contributory in 46% -Causal in a further 10% Good judgement -Mitigated against a worse outcome in 13%

22. PST Panel Assessment Team & Social behaviours -Negative effect in 18% -Positive effect in 10% Communication behaviours -Negative effect in 22% -Positive effect in 21%

23. PST Reporters’ Comments Defective JudgementPoor Teamwork Anaesthesia 56% (74/133)14% (18/133) Intensive Care 17% (6/36)5.5% (2/36) Emergency Department 47% (7/15)20% (3/15)

24. PSTRecommendations Education Introduction of safety training into all anaesthetic, intensive care and emergency department curricula at the earliest possible stage Provision of HF training as part of corporate mandatory training for all members of staff who work with patients with difficult airways Opportunity for multidisciplinary teams working with the difficult airway to train together within simulated scenarios to practise technical and non-technical skills

25. PST Guidelines and protocols Guidelines and emergency algorithms should be immediately available in all clinical areas where airway emergencies may arise Team training scenarios should reinforce the use of guidelines within the clinical arenaRecommendations

26. PST Building an organisational safety culture Airway incidents, including near misses, should be routinely reported and regularly audited Investigations into adverse events should be performed according to best practice to determine if changes need to be made to make the systems safer for future patientsRecommendations

27. PST Improving communication Organisations should encourage the use of routine briefing and debriefing - as recommended by the NPSA. In particular this should occur before management of an anticipated difficult airway and after such management or a critical airway incident Consultants and senior staff should lead by example and use briefing and debriefing techniques in these clinical situationsRecommendations