1. Human Factors Concepts and Cascade
Considering Human Factors (HF) in the provision of
safer care

2. Human Factors: our own definition
Human Factors look at how we work together and the parts of being human that impact on us all when we interact. By focusing on these human factors we can work together better for everyone’s benefit and, if things go wrong, we can share the learning to keep everyone safe

3. WHY do we want to adopt a Human Factors approach in our Trust?
…because everything we do affects us and all those we work with or look after and so - if we truly share and learn - then everyone can feel supported and cared for

4. Being human makes us…
Inventive Resourceful Wonderful Fallible!

5. We all make mistakes…
A tired doctor prescribes the incorrect dose of a drug, the pharmacist is too busy to check the chart, the nurse who gives the drug is not familiar with it but is about to go on break so gives the drug without having it checked by a second person, the patient is given the wrong dose and suffers an adverse reaction…

6. Are the following causal factors for this error True / False?
Poor teamwork
Poor leadership
Emergency procedures ignored
Circumventing safe systems
Correct equipment not available
TRUE / FALSE
TRUE
FALSE

7. Human error 60-70% of all clinical errors involve human error
Experts estimate 50% of clinical errors are preventable
Errors can be latent e.g. in the way a system is designed or managed
Errors can be active e.g. unsafe acts committed by people in direct contact with the patient
The other 30-40% of clinical errors involve equipment faults (data from CHFG)

8. Reflection
What adverse events have happened / are happening here in our Trust?
What were / are the impacts of these?

9. Situational awareness
Human Factors that might impact your performance
Communication
Behaviour
Environment
Culture
Cognitive ability
Leadership
Situational awareness
Stress / Fatigue
Equipment
Workload
Teamwork
Decision making

10. Human Factors Behaviours which encompass:
Cognitive skills e.g. thinking, situational awareness and decision making
Interpersonal skills e.g. communication, team working and leadership

11. How we think – dual process
AUTOMATIC
ANALYTIC
Working memory
Not involved
Involved
Awareness
Low
High
Action
Reflexive, skilled
Deliberate, rule-based
Speed
Fast
Slow
Effort
Minimal
Considerable
Errors
Common
Few

12. AUTOMATIC thinking
I drive slowly down the street whilst looking for a specific address. Which of the processes is automatic:
Driving down the street?
Looking for a specific address?
Automatic thinking depends largely on the recognition of repeated patterns…

13. Pattern Recognition
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14. Pattern Recognition
Our subconscious uses learned knowledge and experience to find patterns
Experts in a subject are likely to recognise a pattern more quickly than those who are not experts because they have more patterns 'programmed' in
Because the process is unconscious there is a substantial risk that confirmation bias (attention to data that support the presumed diagnosis and minimising other information) can cause a diagnosis to be missed, because the pattern identified may not be correct

15. Errors associated with AUTOMATIC thinking
Omission when something should be done but nothing is e.g. missing a check on a checklist when distracted
Commission when nothing should be done but something is e.g. running a red light when CD track changes
Substitution when something should be done but something else is e.g. opening oven instead of fridge to get some milk

16. Errors associated with AUTOMATIC thinking
What are your examples of these at work?

17. What impairs ANALYTIC thinking?
Emotional State Negative emotions (anger / anxiety / frustration)
Tiredness and Fatigue Aggravated by sustained concentration and stress or by long periods of high-intensity effort, sleep deprivation and other life stresses
Multiple Interruptions Slow processing speed is prone to interruption and repeated backtracking then required

18. Errors associated with ANALYTIC thinking
What are your examples of these at work?

19. Situational awareness and decision making
Gathering a complete picture of the environment about you (relevant to current task)
Using this picture to form an accurate mental model of the status of your current task
Your model is based on both current information and your past experience
You use your model to anticipate what is likely to occur as a result of your / your team’s actions or inactions
You make decisions based upon these predictions

20. Loss of situational awareness (SA)
SA is lost when those in a team fail to share their mental models with each other (e.g. no pre-briefings)
SA is lost when communication is absent or ineffective (e.g. not sharing important observations)
SA is lost when different assumptions are made by different parties (e.g. absence of protocols / SOPs or failure to follow them correctly)
SA is lost when fixation on one thing occurs – to the exclusion of everything else
In aviation almost 90% of accidents (involving human error) are due to the crew losing SA

21. What affects your SA?
Reflecting upon the causal factors of patient safety incidents can reinforce the message that even highly trained professionals, used to highly technical tasks, can find themselves in circumstances where their situational awareness has diminished to the point of disaster…

22. How do you maintain SA?
Rehearsals, simulations and briefings help to prepare people for different situations and highlight awareness of potential pitfalls
Pre-determined, rule-based decision making can help with following correct protocols and procedures
Constant communication / narration about what is happening in the live environment
Be vigilant about and be prepared to challenge those who may have become fixated on one thing
De-brief and share the learning for next time

23. Interpersonal skills; leadership and team working
As teams come together, there are often multiple leaders – medical, managerial or other – as well as a hierarchy system
A hierarchy gradient can prevent team members from voicing their concerns when safety may be at risk
Co-ordinating a team requires good SA
Important to be explicit about who is managing the situation at any given time (may change)

24. Good Teamworking
In addition to the performance of technical tasks, good teamworking involves:
Supporting others – practically / emotionally
Solving conflicts – avoiding ‘groupthink’
Exchanging information – both verbal and non-verbal
Co-ordinating activities – delegating to those with the appropriate expertise

25. Cascade of HF Concepts
How do we get our teams to participate in discussing the core messages of HF?
How do we deliver the message according to our audience?