06 FYi • Risk


“HUMAN FACTORS” AND MEDICAL ERROR


Medicine has learned much from other high-risk industries such as aviation and off -shore drilling. Dr Michael Moneypenny explains how the study of “human factors” can enhance patient safety


A 1.


GREAT teacher of mine, Dr David Gray, once told me “defi ne or die”. What then are “human factors”? There are


numerous defi nitions out there, some simpler than others. The UK’s Clinical Human Factors Group


(CHFG) describes it as: “Enhancing clinical performance through an understanding of the eff ects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.” This doesn’t lend itself to being easily memorised, so if we apply the KIS (keep it simple) principle then the term “human factors” may be defi ned as:


All the things that aff ect human performance


2. The fi eld of study of all the things that aff ect human performance.


Performance modifi ers Whenever you are carrying out a task there will be internal and external modifi ers of your performance. As I sit here writing this article these include: the uncomfortable wooden chair I’m sitting on, the distractions through the window, the copy deadline and lack of sleep. They might also include: the type of computer and word processing software I’m using and that I’ve had breakfast and two cups of tea. If you think back to your last insertion of an


intravenous cannula you may be able to identify the human factors which aff ected your performance such as tiredness, number of jobs still to do, audience (including the patient), number of attempts already made, familiarity with the technique, lighting, and so on. Until recently, in medicine anyway, the idea that your performance is aff ected by these modifi ers was neither much appreciated nor understood. The fi rst change which occurred was an


appreciation that medicine is a high-risk industry; in the UK thousands of patients are killed or harmed every year due to mistakes made by healthcare professionals. Once this had been acknowledged, the lessons learned and vocabulary from other high-risk industries, such as aviation, off -shore drilling and nuclear power, were adapted and translated into healthcare.


Analysing factors How then can “human factors” help us avoid medical error? Through the study of what aff ects human performance we can try to


Internal modifi ers Emotional state


Concentration on task Expertise with task


Ability to communicate


minimise (never “eliminate”) human errors as well as minimising their eff ects. One may wish to divide the modifi ers into internal and external. (See the table above). An appreciation of human factors can help us understand what internal and external modifi ers are aff ecting our abilities. It may also allow us to see which modifi ers are potential causes for mistakes and allow us to redress these.


The value of simulation Attending courses at a simulation centre may help you identify internal modifi ers contributing to your mistakes. Video-assisted debriefi ng allows you to refl ect on your performance. With the help of a facilitator and your peers, you may learn where your strengths and weaknesses are. In situ simulation involves using the mannequins in the workplace; this is where external modifi ers may be discovered such as lack of equipment, lack of support, organisational blind spots, etc.


Getting started You can start applying the lessons of human factors research today. An important fi rst step is accepting that we are all human and will inevitably make mistakes no matter what stage we are at in our careers. Ask yourself: where are your strengths and


weaknesses (and how might you fi nd out about them)? What can you do to address these? What are the things in your workplace which may lead to human error? Who can you talk to in order to remove or minimise these risks? Human factors provides us with the vocabulary to talk about what is going wrong and the tools to mitigate this. Self-awareness in your day-to-day work will


help you admit when you are tired, stressed or distracted. These human factors increase the risk of making a mistake, and are particularly relevant in situations where you are required to make complex calculations in drug dosages or equipment settings. Taking time to double-check your decision-


External modifi ers Design of equipment


Support from senior Training


Rota intensity


making is one useful way to start “error- proofi ng” your work. As trainee doctors, you might also fi nd


yourself trying to remember 10 diff erent things to do – again increasing the likelihood of mistakes. The human brain can only have seven or eight things at its forefront at any one time, so consider drawing up a checklist to give yourself a visual reminder. There are many more tips and techniques


available and applying these human factors concepts in your practice will make you a better doctor.


Recommended watching: CHFG video, Just a routine operation - www. tinyurl.com/fyichfg


BBC Horizon programme: How to Avoid Mistakes in Surgery (available on YouTube)


Recommended reading: • Sidney Dekker, The Field Guide to Understanding Human Error


• • • Rhona Flin et al, Safety at the sharp end


Atul Gawande’s books: Complications, Better and The Checklist Manifesto


Alissa Russ et al. “The science of human factors: separating fact from fi ction” in BMJ Quality & Safety - www.tinyurl.com/ndk4mcz


• Charles Vincent, Patient Safety


Dr Michael Moneypenny is a consultant anaesthetist and expert in the fi eld of human factors in healthcare. He is also director of the Scottish Clinical Simulation Centre


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