1. Using Human Factors to Enhance Patient Safety Neal Jones Assistant Director of Safety & Governance

2. Human Factors Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and the organisation on human behaviour and abilities, and application of that knowledge in clinical Settings. Ken Catchpole, CHFG

3. Why Human Factors ?

4. November 2013

5. The NHS would be a much safer place – If it wasn’t for those pesky humans!

6. Everything would be fine if – “ people simply applied their training in line with our policies each and every day that they came to work” Is it inexcusable that they don’t? And who’s fault is that?

7. The solution

8. Train all staff in Human Factors and the NHS will be a safer place Any Questions ?

9. Training staff to recognise error and understand why the systems are failing, then throwing them back to work within those systems = Culture of vulnerability and contempt

10. HF Education must be aligned to system re- design

11. Environmental and equipment re-design

16. Amalberti – Model of migration and transgression (Risk acceptance) – Driving version Illegal-illegal Normal-illegal Legal Personal gain Performance Pressure related variance in practice Safety 70mph 77mph85mph Incident* Accident Near miss Expected safe zone

17. My findings = people normalise error to survive the combination of ineffective environments and systems thrust upon them in highly stressful working environments ! Blood Culture contaminates

18. How to Guide – Deconstruct the RCA’s to identify the system drivers of unwanted behaviours/error causation. – Observe normal practice to differentiate between the exception and the norm – Refine the systems to mitigate the unwanted behaviours – Re-train the teams in the new systems – Train the teams in Human Factors to create a resilient workforce

19. It isn't the exceptional behaviours that require most effort/attention to reduce harm. It is the custom and practice adopted to compensate for inadequate process or excessive pressures that create the conditions for repeated episodes of patient harm.

20. Theatre Never events – Our story

21. The problem! 12/13 The organisation had multiple surgical never events. There were significant parallels in the error causation factors. Human Factors elements were identified as prime error causation components

22. The proposed solution A Human Factors based re-design of the identified failing safe systems Targeted intra-professional Human factors team training for every member of the Theatre clinical workforce to:- – Increase error reporting through cultural change – Create a resilient workforce that can identify and mitigate risks in real time.

23. The Project Pre-interventional measurement – Reporting/Harms Surgical safety group – Multidisciplinary System redesign – Human factors based Course design – recognised error causation factors Course delivery – 268 staff Post interventional measurement – Reporting/Harms On-going evaluation – Reporting/harms

24. The new tools

26. “I believe in resource management - you’re the resource and I AM THE MANAGEMENT!!!!”

27. H - Have you noticed this? A - Ask did you hear my concern/suggestion? L - Let them know this is a patient safety issue T - Tell them to STOP until it is agreed that it is safe to continue Human factors trained student ODP utilised HALT to prevent a surgical never event The HALT tool has been utilised 80 times to protect patients since its introduction

28. The course Discussion based program to explore the teams current practice and behaviours and form contextual learning that can be implemented as corrective measures with immediate effect

29. The content 08:30Registration & Coffee 09:00Welcome & Housekeeping 09:15Human factors in Health Care 10:30Coffee 10:45Human performance 11:45Situational awareness 12:45Lunch 13:30Decision making 14:30Team dynamics 15:30Coffee 15:45How to use/Checklists/Halt tool 16:30Video based theatre error case discussion 17:00Close

30. Permission to Speak!! (leadership statement) ‘If at any point you see me doing something that you either don’t understand or feel may be incorrect then please let me know! ‘At worst I can educate you as to why I am doing things this way, at best you will prevent me from harming both this patient and risking my own career’

31. 6 month pre and post intervention analysis April – Sept 2013 (set 1)

32. March – Sept 2013 (Set 1) Theatre List details Incorrect = 34 Documentation = 19 Failure of device or equipment = 11 Treatment inappropriate= 12 (3 moderate harm) Accident of some other type= 11 (1 moderate harm) Unavailability of device = 8 Failure to note relevant info= 7 Other = 7 Unintended Injury during OP= 6 (3 moderate harm) Inadequate consent = 5

33. Datix Oct 2013 – March 2014 (set 2)

34. Sept 2013 - March 2014 (set 2) Delay= 116 Theatre list details incorrect= 68 Unavailability of device = 17 Failure of a device = 16 ( 1 moderate harm) Injury from dirty sharps= 14 Failure to note relevant info= 10 Unintended Injury during OP= 10 ( 1 Moderate harm) Communication failure= 7 Accident of some other type= 6 Patient Incorrectly identified = 7

35. Thematic analysis 6 month pre/post Increased reporting – Set 1 = 121 – Set 2 = 275 127% Reduction in episodes of harm (relative) – Set 1 = 20% – Set 2 = 10% – 50% reduction in episodes of harm

36. Long term performance 2012-2015 126% Increase in error reporting of since project implementation

37. 27% increase in episodes of No harm since project implementation

38. 59% Decrease in episodes of Low harm since project implementation

39. 70% Decrease in episodes of Moderate harm since project implementation

40. Fiscal YearSevere harmDeathNever Events 2012/13103 2013/14000 2014/15000 Fiscal YearTheatre activity % increase from start date 2012/1317095 ↔ 2013/1418707↑ 9.40% 2014/1518278↑ 6.90% Theatre Activity 2012-2015 comparison Episodes of Severe harm/Never events

41. HF should be part the everyday language within your organisation

42. Thank you for listening……. Questions T