1. Human Factors

2. ‘Most avalanche fatalities in North America result from slab releases triggered by either the victim or a member of the victim’s party’.
‘By investigating avalanche accidents, we’ve learned that the human factor is a major contributor’
Fredstone et al. (1994)
Human Factors in the outdoor setting

3. ‘…our results show that the number of avalanche accident injuries and death can be substantially reduced if avalanche safety training courses focus more attention on highlighting the importance of human factors in causing avalanche accident deaths and reducing survival’.
Uttl et al. (2010)
Implications for training.
Training should include practical, theory and Human Factors.

4. ‘In aviation, human factors is dedicated to better understanding how humans can most safely and efficiently be integrated with the technology. That understanding is then translated into design, training, policies, or procedures to help humans perform better… because improving human performance can help the industry reduce the commercial aviation accident rate’.
Aero Boeing (2016)

5. 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.
Shropcom’s own definition

6. 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.
Shropcom’s ‘why’.

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

8. 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…
Fatigue
Pressure
Lack of knowledge
Complacency
A practical example of how Human Factors may impact an outcome.
… the outcome

9. Just a Routine Operation

10. Reflection
Reason (2000)

11. Human Factors that might impact your performance
Lack of Communication
Lack of Resources
Distraction
Lack of Teamwork
Stress
Complacency
Lack of Awareness
Lack of Knowledge
Pressure
Aviation’s ‘Dirty Dozen’.
The 12 most common Human Factors that affect aircraft maintenance, all of which could apply to healthcare.
Lack of Assertiveness
Fatigue
Norms
De Decker and Roos (2017)

12. 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)
CHFG (2017)

13. Identifying Human Factors – how does this translate into your setting?
What are the Human Factors that may cause an incident in your settings?

14. Human Factors Consists of behaviours which encompass:
Cognitive skills e.g. thinking, situational awareness and decision making
Interpersonal skills e.g. communication, team working and leadership

15. Cognitive Skills

16. 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
These processes happen concurrently.

17. 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…

18. Pattern Recognition
Aoccdrnig to rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be at the rghit pclae. The rset can be a toatl mses and you can sitll raed it wouthit porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe

19. 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 (only attending to data that supports what we expect and ignoring all other information) can cause a diagnosis to be missed.

20. 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

21. 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.

22. 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

23. 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.

24. Interpersonal Skills

25. Considerations for 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).

26. 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.

27. Further information
Further information can be found on Shropshire Community Health NHS Trust’s webpage.

28. References
Aero Boeing (2016) Human Factors [online], (accessed 21st December 2016)
CHFG (2017) What is Human Factors? [online], (accessed 26th April 2017)
De Decker, R., and Roos, J (2017) ‘Human factors: Predictors of avoidable wilderness accidents?’, South African Medical Journal, vol. 107, no. 8, pp
Fredstone, J., Fesler, D., and Temper, B. (1994) The Human Factor – Lessons for avalanche education, Montana State University Library
Reason, J (2000) ‘Human error: models and management’, British Medical Journal, Vol. 320, no. 7237, pp. 768–770
Uttl, B., Kissinger, L., McDougal, J., Mitchell, C., and Uttl, J. (2010) Human Factors in avalanche avoidance and survival: Consequences of violating the rules of safe travel, 2010 International Snow Science Workshop