A Focus On Human Factors

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A Focus onHuman FactorsShare2Care

Why is human factorsan important topic?Human Factors, often referred to as ergonomics,is an established scientific discipline used in manysafety-critical industries, such as airlines and oil.Every day in the NHS, tens of thousands ofpatients are treated safely by dedicated healthcareprofessionals who are motivated to provide highquality and safe clinical care. For the vast majorityof patients, the treatment they receive alleviatesor improves their symptoms and is a positiveexperience. However, an unacceptable number ofpatients are harmed as a result of their treatment oras a consequence of their admission to hospital.A failure to apply human factors principles is a keyaspect of most adverse events. “In healthcare 80% of errors areattributed to human factors at individuallevel, organisational level, or commonlyboth.” (National Patient Safety Agency, 2008)Understanding the importance of Human Factors,and how its concepts can be applied by individualsand teams is fundamental to improving patientsafety.4What is Human Factors?Opening the Door to Change (2018)Human Factors encompasses all of the factorsthat can influence the behaviour and performanceof human beings in a system. It allows us tounderstand how people perform under differentcircumstances and why errors happen.In December 2018, the Care Quality Commission“Enhancing clinical performance throughan understanding of the effects ofteamwork, tasks, equipment, workspace,culture and organisation on humanbehaviour and abilities and application ofthat knowledge in clinical settings”Never Events are serious incidents that areconsidered to be wholly preventable. Howeveracross the NHS, there were 468 incidents classifiedas Never Events between 1 April 2017 and 31March 2018.(NHS England, 2013).This issue of Share2Care aims to improveawareness of Human Factors and the role youcan play in increasing patient safety. Please note,the case studies within this issue did not occur atELHT but illustrate that severe incidents can occuranywhere, to anyone, at any time.(CQC) published a report entitled “Opening theDoor to Change” which examines the issues thatcontribute to the occurrence of Never Events andwider patient safety incidents. “96% of Never Events reported in2017/18 should have been preventablewith regular actions by humans” (CQC, 2018)According to the CQC report, too many peopleare being injured or suffering unnecessary harmbecause NHS staff are not supported by sufficienttraining, particularly around Human Factors, andbecause the complexity of the current patient safetysystem makes it difficult for staff to ensure thatsafety is an integral part of everything they do.Although healthcare is by its nature ‘high risk’, thereview found that due to increasing pressures withinthe NHS, this is not consistently reflected in itsculture and practice. The CQC is calling on the NHSto promote a change in safety culture so that safetyis given the priority it deserves.For more information: The full report is available todownload on the CQC website: www.cqc.org.uk “NHS staff do a remarkable job tokeep patients safe. But despite theirbest efforts, never events and otherpatient safety incidents continue tohappen. In theory these events areentirely preventable: in practice toomany patients suffer harm”. (Professor Ted Baker, Chief Inspector ofHospitals, 2018)

Errors and IncidentsThe Swiss Cheese Model “We all make errors irrespective of how much training we possessor how motived we are to do it right” (Health and Safety Executive, 1999)Healthcare professionals are human beings and,like all human beings, are fallible. In our personaland working lives we all make mistakes in thethings we do, or forget to do, but the impact ofthese is often non-existent, minor or merely createsinconvenience. However, in healthcare there isalways the chance that the consequences could becatastrophic.Understanding Human Factors helps us build betterdefences into our systems in order to prevent orreduce the likelihood of serious error resulting inharm to a patient by:Human Factors ‘Dirty Dozen’The ‘Dirty Dozen’ refers to twelve of the mostcommon factors that influence people to makemistakes and errors that can potentially lead toharm (Dupont, 1993)1Communication2Distraction3Lack of resources4Stress5Complacency6Lack of teamwork7Pressure8Situational awareness9Lack of knowledge Allowing us to understand why we make errors Improving our safety culture within teams andthe organisation Enhancing teamwork and communication Identify “what went wrong”10Fatigue Helping us predict “what could go wrong” in thefuture11Lack of assertiveness12 Improving the design of the system/processeswe work inCultural Norms“the way we do things around here”6(Reason, 1990)In any system there are many levels of defence (for example checking of drugs before administration,a pre-operative checklist or marking a surgical site before an operation). Each level of defence has little‘holes’ (latent conditions) which are caused by poor design, decision-making, procedures, lack of training,limited resources, staffing levels etc.If these holes become aligned over successive levels of defence, they create a window of opportunity for apatient safety incident to occur. Latent conditions also increase the likelihood that healthcare professionalswill make ‘active errors’ (for example whilst delivering patient care).When a combination of latent conditions and active errors causes all levels of defences to be breached, apatient safety incident occurs.fovelsLeencdefeLatent conditions:poor design, procedures,management decisions etc.Active errorsPatient safety incident

Key LearningRaising AwarenessOn the surface this could appear to be a tragic butunavoidable event resulting from an unexpected butrecognised complication of anaesthesia. However,the outcome could have been quite different ifHuman Factors had been taken into account byeveryone involved. Every member of the teamtreating Elaine was experienced and technicallyhighly competent, yet the series of events andactions still resulted in her death.As a result of this incident, Elaine’s husband,Martin Bromiley has been continuously raisingthe profile of the importance of Human Factorsin healthcare and is the founder of the ClinicalHuman Factors Group – a charity working to makehealthcare safer.A detailed investigation highlighted some of thesefactors:Loss of situational awarenessThe stress of the situation meant that theconsultants involved became highly focussed onrepeated attempts to insert the breathing tube.Case study 1:just a routine operationElaine Bromiley was a fit and healthy young woman who was admitted to hospital for routine sinus surgery.During the anaesthetic she experienced breathing problems and the anaesthetist was unable to inserta device to secure her airway. After 10 minutes it was a situation of ‘can’t intubate, can’t ventilate’; arecognised anaesthetic emergency for which guidelines exist.For a further 15 minutes, three highly experienced consultants made numerous unsuccessful attempts tosecure Elaine’s airway and she suffered prolonged periods with dangerously low levels of oxygen in herbloodstream. Early on nurses informed the team that they had brought emergency equipment to the roomand booked a bed in intensive care but neither were utilised.Thirty-five minutes after the start of the anaesthetic, it was decided that Elaine should be allowed to wakeup naturally and was transferred to the recovery unit. When she failed to wake up she was then transferredto the intensive care unit. Elaine never regained consciousness and after 13 days the decision was made towithdraw the ventilation support that was sustaining her life.As a result of this they lost sight of the biggerpicture i.e. how long these attempts had beentaking. This ‘tunnel vision’ meant they had nosense of time passing or the severity of thesituation.Perception and cognitionActions were not in line with the emergencyprotocol. In the pressure of the moment manyoptions were being considered but they were notnecessarily the options that made the most sensein hindsight.TeamworkThere was no clear leader. The consultants in theroom were all providing help and support but noone person was in charge throughout. This led toa breakdown in the decision making process andcommunication between the three consultants.Culture and assertivenessNurses, who sensed the urgency early on, broughtthe emergency kit to the room, and then alertedthe intensive care unit. They stated that thesewere available but did not raise their concernsaloud when they were not utilised. Other nurseswho were aware of what was happening did notknow how to broach the subject. The hierarchy ofthe team made assertiveness difficult despite theseverity of the situation.For more information: https://chfg.org/Watch: A full video of ‘Just A Routine Operation’ isavailable on You TubeSource: NHS Institute for Innovation andImprovement (2013)

Key Components ofHuman FactorsOrganisational Safety “Culture can be best understoodas "the way we do things aroundhere". An organisation's culture willinfluence human behaviour and humanperformance at work.Poor safety culture has contributedto many major incidents and personalinjuries.” Team Resource Management (TRM)TRM is about the study of how we interact withindividuals and teams, and how our behaviour canimpact upon practice and safety. The key elementsthat impact on our work are: Communication: The importance of havingeffective communication in our day to daywork activities. It helps us build a team with acommon cause and improves decision marking. Leadership: Leaders who have the ability toinfluence, inspire and direct actions to attain adesired objective. Followership: The ability or willingness to followa leader, take direction, be part of a team and todeliver what is expected of you.(HSE, 2018)Organisational safety is a high priority for the Trust.In order to ensure we have an excellent safetyculture, it is important that: Our systems are designed to help us do our jobswhilst keeping patients and staff safe The working environment is fit for purpose The correct equipment is available and in goodworking order. The main characteristics of a safety culture are: Open: Staff feel comfortable discussingpatient safety issues and raising concerns withcolleagues and senior managersJust: Staff, patients and carers are treatedfairly, with empathy and consideration whenthey have been involved in an incident orhave raised concerns about safety standards.There are clear guidance for behaviour that isunacceptable. Reporting: Staff are able and feel confident inreporting incidents and near misses Learning: We learn from safety lessons andshare this learning across the Trust Informed: The Trust has learned from previousexperience and works hard to identify andmitigate future harms. Situational Awareness: Understanding of whatis happening around you, what others are doingand what will happen next.Anticipation and Planning: The ability toidentify potential needs, and prepare bothequipment and environment to enable efficientdelivery of patient careDistribution of Workload: Appreciatingwhat causes an increase in workload and theimplications that an excessive workload canhave on us and our behaviour.Error Recognition: The ability to recognisewhen an error could be happening and cautionshould be applied to reduce the risk TRM aims to “develop positive attitudesand behaviours towards teamwork skillsand human performance helpingto reduce the number or minimise theimpact of teamwork related errors.” (Eurocontrol)Case Study 2: Controlled Drugs“Some years ago they made Temazepam acontrolled drug. This meant that every time I hadto give it, I had to lock up the drug trolley, wait fora colleague to come with me, both of us take theprescription cart to the drug cupboard, count thetablets in the bottle, take out the dose, fill in thebook, go and check the identity of the patient andprescription again together and then give it.Key LearningOn my ward, we often had up to 12 patients needingTemazepam so suddenly the evening drug roundswere taking forever! The drug cupboard was right atthe other end of ward. In the end we started takingthe bottle out of the drug cupboard at the start of theround and putting it in our pocket.Staff do not consider it likely there will be negativeeffects for the patient or consequences forthemselves. The process or rule may not appear tohave value.We’d then just fill out the book as we went along;we had to check all the controlled drugs later in thenight anyway. We all knew we were doing it wrongbut it just seemed crazy trying to do it the right waywhen we were so busy and the reason for changingthe policy seemed to be more about it needing to becounted to prevent abuse rather than it presenting arisk to the patients.”In this example we see evidence of why staff maydeliberately flout the rules:There is a perceived benefitLess trouble for the staff, saves time, reducesdistractions while doing the round.Assumed absent or minimal consequencesThe greater the benefits and lower the likelyconsequences, the more common it is for people to‘migrate’ towards working in ways that they know tobe wrong or that break the rules.Over time these ways become normalised and areintegrated into the culture – “This is how we do ithere”.Source: Patient Safety First (2009)

How is‘Human Factors’ beingused within the Trust? Moving the focus of investigations undertakenin the Trust from “who did” to “why did” theincident occur Incident Investigations Quality ImprovementAcute Kidney InjuryIntroduction of Round Table de-brief discussionafter a serious incident that provides a safespace for staff to have an open and transparentdiscussion about the incident, so they canunderstand what happened, why it happenedand what could they change to improve safety.Moving the focus of investigations undertakenin the Trust from “who did” to “why did” theincident occur. Allowing us to improve safetyby developing safer systems which are there toprotect patients and staff.The solutions developed in response to incidentsare being developed and owned by the teamsinvolved, making it more likely that they will workSharing the learning from incidents across theTrust in a number of different ways (e.g. Share toCare bulletin and meetings, posters, forums etc).Development of “Root Cause Analysis Training”for senior managers and the “Introduction toHuman Factors” course which is available to allstaff.There have been a number of quality improvementsprogrammes on the back of incident reporting andinvestigation, including: Changes to the Nasogastric feeding bundle tostop routine x-ray checks overnight to eliminatehuman error caused by fatigue The development of new pathways fordermatology patients requiring care following aserious in-patient fall. The introduction of nursing and porter checklistsevery time patients are moved from a ward.Thinking Innovatively AboutDistraction: 10,000 FeetIn January 2018, the Trust introduced the “10,000Feet” concept for surgical staff.Based on the ‘Below Ten Thousand’ conceptdeveloped in Australia, when any member of thesurgical team find that noises and distractionsare affecting their performance, staff can use thetrigger phrase “10,000 Feet” to allow staff the timeand space to do their job safely. This could be, forexample, when patients are to be extubated and theanaesthetist needs to focus.Following its implementation, we have seen that: Junior members of the surgical team (includingstudents) feel more empowered to speak up. Staff have more awareness and educationabout how noise and distraction is detrimental topatient safety. Staff are more aware of the need for “below tenthousand moments”. In particular, at Time Outand Sign Out, staff now recognise that theseare the ‘slowing down’ moments that requireteamwork for effective implementation. Everyone has control of the environment andconfidence in calling “10,000 Feet” if at anypoint they feel that noise and distractions areimpeding on patient care.Share2Care

Simulation TrainingThe Education Directorate have developedsimulation training and offer regular sessions,designed to recreate real-life patient scenarios,across all specialities. Key concepts of HumanFactors, such as situational awareness,communications, leadership and teamwork, areinterwoven into the training.Some examples include:MaternityA ‘Lucinda’ doll simulation trainer was purchasedusing money from Health Education England’s‘Better Training, Better Births’ fund. This enabled theMidwifery Practice Educators to provide simulationtraining for NICU with locality-based scenarios witha MDT approach.TheatresTeams in theatres have utilised the offer of in-situsimulated learning to reinforce their awarenessaround Human Factors. Simulations have takenplace in anaesthetic rooms, recovery and theatre,using an MDT approach with multi-professionalteamworking. Theatres are also using simulationsto learn from patient safety incidents wherebyteams involved can re-create the incident withinthe environment and unpick the learning from thescenario.Emergency DepartmentIn response to feedback from ED staff and NWAS,regular MDT simulation training sessions look atthe sterile cockpit of handover and the receipt ofspecific patient groups.Assistant PractitionersSimulation training has been provided to AssistantPractitioners in order to support them in undertakingthe role of second checkers so patients receivemedication in a safe manner.For more informationPlease contact your Practice Educator or theEducation Department.Case Study 3:Retained Foreign Object Post-ProcedureA 55-year-old man was admitted to hospital forelective (non-emergency) liver surgery. At thebeginning of the surgery, the team completed aninitial count of all the swabs and instruments to beused in his operation, which was then written on thewhite board in the operating theatre, as per safetyguidance.During the surgery a total of five abdominal swabswere used. Two abdominal swabs were used inthe first instance (one to clean the surgical site andanother for blood) and placed in a bowl after use. Afurther three abdominal swabs were placed underthe liver to lift the liver up so that the surgeon hadbetter access to it, of which the team were informed.At the end of the operation just before the teamclosed the abdomen, the team completed anothercount. A number of smaller swabs (some clean andsome used) were counted in to the bowl on top ofthe two abdominal swabs already in the bowl.The two abdominal swabs were not removed fromthe bowl and therefore not seen during thepre-closure count, as a result it was thought thatthere were actually five abdominal swabs in thebowl and so five were crossed off the white board.The surgical wound was closed and the final countperformed (which counts only those swabs that hadnot previously been counted). The three abdominalswabs were not identified as unaccounted for andwere left behind in his abdomen when it was closed.They were identified a few days later following anx-ray and the patient needed a further operation toremove the swabs. He made a full recovery but wasin hospital for a week longer than necessary.Key LearningThis type of incident is preventable becausehealthcare providers are expected to carry outspecific counting and checking procedures asspecified by safety guidance (for example NationalSafety Standards for Invasive Procedures NatSSIPs). These standards support safe andconsistent practice in accounting for all items usedduring invasive procedures and in minimising therisk of them being retained unintentionally.A local investigation identified the following issues: Not following policyThere was a Trust policy for counting itemsduring the procedure, but that this was notcompletely followed. Variation in practiceSwab counting across the organisation variedand there was no clear guidance about whatshould be included in the count. Complacency: There was a belief that theabdominal swabs were too big to be left insidethe abdomen unintentionally Inexperience and distractions: The teamconcerned were relatively junior and theinvestigation identified several interruptions thatoccurred during the swab counting process.Source: CQC (2018)

Would You Like To Learn MoreAbout Human Factors?The CQC report states that 96% of NeverEvents could have been prevented if moreattention had been paid to Human Factors.“Everyone can play a part in makingpatient safety a top priority. But there isa wider challenge for us all to effect thecultural change that we need, to have thehumility to accept that we all can makeerrors – so we must plan everything wedo with this in mind”.(Professor Ted Baker, 2018)What does this mean in practice?To find out more, why not attend our 1-daytraining course: Introduction into HumanFactors?This course is designed to help staff gain anunderstanding of Human Factors approachesand how to apply these to help improve safetywithin our workplace.It will help you gain a greater understanding of: The principles of Human Factors and whyerrors occur;The relevance of Human Factors to theimprovement of quality and safety inhealthcare;Human Factors as a ‘way of thinking’ aboutevery day work and how it relates to patientcare;How to identify potential Human Factorserrors and ways to mitigate them to improvepatient safety in your own areas;How the culture we work in influences thecare we give;The training is suitable for staff that are newto the concept of Human Factors as well asthose who would like to refresh their existingknowledge.To Register: For dates, times and details of howto book, please visit the Learning Hub.Patient Safety AlertNHS/PSA/W/2016/011‘Risk of severe harm and death due to withdrawing insulin from pen devices’The above Patient Safety Alert was originally issued by NHS Improvement in November 2016.At ELHT, the contents of this alert were discussed at Patient Safety and Risk AssuranceCommittee, where a nominated lead was selected to co-ordinate a response which wassubsequently uploaded onto the Central Alerting System (CAS).After reviewing the response and assurance, it appears that the alert was only shared withclinicians linked to the Diabetes Team. We need this alert to be cascaded to all clinical staffinvolved in the administration of insulin.Key Learning:“Communication often appears at the top of contributing and causal factors in incident reports, andis therefore one of the most critical human factor elements” (Dupont, 1993).What Can I Do?Please can ALL staff potentially involved in the administration of insulin read a copy of this alert?Where Can I find a copyOn the NHS Improvement atient Safety Alert - Withdrawing insulin frompen devices.pdf

Share2Care is published monthly. Hard copies are distributed across the Trust with soft copies ofall editions available for downloaded from OLI.Share2Care

A failure to apply human factors principles is a key aspect of most adverse events. “In healthcare 80% of errors are attributed to human factors at individual level, organisational level, or commonly both.” (National Patient Safety Agency, 2008) Understanding the importance of Human Factors