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Using a ‘Human Factors’ approach to understand complex safety challenges

  Category: Human Factors  | Comments (0)

‘Human Factors’ is a diverse and multi-faceted scientific discipline concerned with analysing and enhancing the interactions amongst humans and the other elements of a specific system, with a view to optimising system performance and human well-being. With specific reference to healthcare, Human Factors work has a diverse set of inter-related goals including enhancing clinical performance, improving patient safety and promoting occupational safety and staff well-being.

In the United Kingdom, the most prominent organisation dealing with Human Factors in Healthcare is the ‘Clinical Human Factors Group’, founded by airline pilot Martin Bromiley. In 2005, Martin’s wife passed away due to unexpected complications encountered during what should have been a routine operation. Martin participated in the investigation into his wife’s death and utilised accident investigation methodology borrowed from the aviation industry to unravel the multiplicity of complex events that occurred during the operation. The investigation unearthed numerous deficiencies such as:  operating theatre protocols which were not clear or well-rehearsed; a lack of familiarity and understanding amongst staff in the use of certain equipment; a lack understanding of techniques for maintaining situational awareness during emergencies; and a lack of open communication both at the moment of the emergency and in the organisation as a whole.

As a practising clinician, I can recall multiple instances when Human Factors’ limitations have led to less than optimal patient care. For example, there is the time that the new, yet poorly constructed emergency buzzer system was too quiet to alert my team to an obstetric emergency. I can recall personally becoming fixated on certain procedures during emergencies to the exclusion of everything else and I have seen team-working fall apart under the pressure of heavy workloads on a number of occasions. In the past decade, a multitude of initiatives have emerged around the globe to try and address Human Factors in healthcare. Examples include:  the WHO Safer Surgery Checklist, designed to enhance team-working and communication in the operating theatre; various product redesigns to reduce operator error and numerous training programs to coach teams and individuals in enhancing situational awareness and addressing cognitive biases such as task-fixation. 

The Improvement Academy will be leading a Community of Practice for Clinical Human Factors for practitioners from Yorkshire & Humber. The aim will be to share existing regional expertise in human factors training and generate new programs through collaboration.

If you would like to join our Community of Practice or find out more about Human Factors in general please contact Del Wijeratne del.wijeratne@bthft.nhs.uk or Deborah Clark Deborah.Clark@shu.ac.uk


Del Wijeratne: Patient Safety Leadership Fellow & Obstetrics and Gynaecology Registrar  

I am an Obstetrics & Gynaecology Registrar spending a year as a Patient Safety Leadership Fellow. I am working on projects in a number of areas:

Human Factors:

I am working on a training package based upon the emerging evidence around effective surgical checklist implementation. I am also helping to set up a Community of Practice for teams undertaking Human Factors training across Yorkshire.

Complex-Adaptive-Systems in Healthcare:

I am working on using a new narrative capture tool as a patient safety thermometer. I am also working on a team-based reflection process which aims to look at near-miss events within a complexity framework.



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