1. Human factors Situation awareness & Mental models Decision Making Communication Assertiveness & Teamwork Leadership & Task Management Wrap Up ERROR & HUMAN FACTORS

2. JUST A ROUTINE OPERATION The real problem isn’t how to stop bad doctors from harming, even killing, their patients. It’s how to prevent good doctors from doing so. Gawande The New Yorker 1999 What happens when a team of experts gets “lost in the fog”…

3.  Describe the experience & skills of the theatre staff; doctors & nurses  Why did the doctors not “hear” the nurses?  Why did the nurses give up?  Why did the doctors persist?  Why did they not take her to ICU?  Who was the leader?  What was their awareness of their situation  What was their plan? These are human factors or ‘non technical skills’ DISCUSSION

4. To err is human Alexander Pope, 1711 James Reason, 1990 Institute of Medicine, 1999 ERRORS DUE TO HUMAN FACTORS ARE UNAVOIDABLE

5. HIGH TECHNICAL PROFICIENCY CANNOT GUARANTEE SAFETY

6.  Analysis of 27,370 occurrences (Jan 02 – June 08)  25 wrong patient & 107 wrong-site procedures  Significant harm inflicted in 5 wrong patient & 38 wrong-site procedures  Main causes wrong patient procedures  Errors in judgement (56%)  Errors in communication (100%)  Main causes wrong-site procedures  Errors in judgement (85%)  Lack of ‘time-out’ (72%)  Equal occurrences non-surgical and surgical procedures Wrong-Site and Wrong Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-reported Occurrences. Stahel, P. Sabel, A. Victoroff, M. et.al. Arch Surg. 2010: 145(10):978-984. HUMAN FACTORS CAN HELP EXPLAIN ERROR

7. REASON: CLASSIFYING HUMAN FAILURE James Reason

8. REASON: SWISS CHEESE

9. REASON SWISS CHEESE

10.  Surgeon  Anaesthetist  Scrub nurse  Anaesthetic nurse/assistant  Other (managers etc.) HUMAN FACTORS APPLY TO ALL TRIBES & CULTURES  Consultant  Registrar  Resident  Registered nurse  Enrolled nurse  Student  Australian  European  African  Asian  Indian

11. Teamwork Mental Model Situation Awareness Communication Task Assistance Graded assertiveness Leadership Delegation ISBAR Debrief Briefs Decision Making STEP Feedback Cross Monitoring Roles Huddle Check Back CallOut Coaching Mutual support HUMAN FACTORS OVERLAP

12. HUMAN FACTORS CAN BE GROUPED Situation Awareness Decision Making Leadership Communication Teamwork Patient Status Plan

13. QUESTIONS?

14.  Human factors:  Is a science  Describes how mistakes & errors occur  Predicts behaviours that can reduce error and/or decrease the harm resulting from error  These behaviours can be arranged into overlapping Categories:  Situation awareness  Decision making  Communication/Teamwork  Leadership/Task management SUMMARY: HUMAN FACTORS