Parallel Session 3.5 Crossing Boundaries to Improve Outcomes


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  • overview
  • We know that things do not always go right! Major disasters – but following common mistakes and practises RF investigation of piper alpha
  • Human Factors scientists / discipline
  • What might these scientists consider – RF detail
  • Why do we need people to understand humans, their behaviour and how they interact with workplace? Exercise to indicate our own fallibility and the ubiquitous nature of this
  • Error major issue in all domains we are aware of
  • Clinical example – contrasting individual blame versus system attention, investigation and adaptation
  • Reason
  • What do other industries do that is different from healthcare? Are there examples we can learn from
  • Airline – humans as hero Work in simulation Not just about the scientists but also about the practitioners taking a human factors approach to their daily work
  • What about healthcare – highly complex challenging workplace
  • Calls for inclusion of human factors to be integrated to healthcare education and the way that we work and think Link to simulation
  • RF Work at on identification and development of NTS taxonomies for some h/c practitioners – GGY work with surgeons & link to simulation
  • What do these things look like and how might use them – link to simulation
  • What else is happening in healthcare – back to surgery – link to GGY RCS and also SPSP
  • An example where HF approach can make a difference to practice of individuals, reliability of system
  • Back to what is human factors about – martin bromiley quote
  • Parallel Session 3.5 Crossing Boundaries to Improve Outcomes

    1. 1. HUMAN FACTORS Dr Rona Patey Consultant Anaesthetist NHS GrampianHead of Division of Medical and Dental Education University of Aberdeen
    2. 2. Who are we?1. Nursing 11%2. AHP 11%3. Medicine 11%4. Healthcare education – undergraduate 11%5. Healthcare education – postgraduate 11%6. Healthcare management 11%7. Human factors research 11% 08. Human resources of 11% 1009. Other 11%
    3. 3. Are you currently working on a human factors initiative? 20% • Yes – still in planning stage 20% • Yes – within my team 20% • Yes – across institutions 0 20% of 100 • No – but I would like to 20% • No
    4. 4. Have you had previous education / training around human factors? 20% • No, not really thought about it 20% • No, but would be keen to know more 20% • Yes, a one off session 20% 0 • Yes, as part of a larger programme of 100 20% • Don’t know
    5. 5. Things don’t always go right!
    6. 6. Human Factors• ‘the scientific discipline concerned with the understanding of interactions between humans and other elements of the system, and the profession that applies theory, principles, data, and methods to design in order to optimise human well being and overall system performance’ International Ergonomics Association 2000
    7. 7. Human Factors• Organisational / • Workgroup(s) / Team (s) management – Team structures / processes – Safety culture – Team leadership – Management • Individual worker leadership – Cognitive – Communication • Situation awareness• Work environment • Decision making – Work environment and – Personal resources hazards (ergonomics • Management of stress • Management of fatigue
    8. 8. Exercise• A picture will appear on the screen for around 15 seconds• Examine the picture closely and look for a change• Raise your hand when you spot a change
    9. 9. Safety• Error is inevitable and ubiquitous! – Humans are fallible Helmreich 1996• Critical incident students reveal that around 80% of underlying issues relate to human factors – Frequently avoidable
    10. 10. Wrist Admitted On 5 fracture six with UTI Medications months ago Mobilises with a frame Lack of staff training Accident TrajectoryPatient Drug ChartCondition Medical Records Ward Workforce & Environment CommunicationThe latent failure model of complex system failuremodified from James Reason, 1997
    11. 11. Safety• Systems should be designed with ‘defenses in depth’ – Organisational, management, equipment design, workspace layout – Should provide the human in the systems with the necessary knowledge and skills to deal with threats in their environment / to act as hero • technical skills are not enough! Reason 1997
    12. 12. Lessons from other industries• Human factors & safety integrated to the core curriculum – undergraduate – continuing professional development• Compulsory adverse event reporting with investigation and learning (organisation and industry)• Briefing and debriefing part of the culture
    13. 13. Lessons from other industries 15/1/2009 Flight 1549 Routine flight from New York to Charlottesville
    14. 14. What about healthcare?
    15. 15. ANTS SystemCategories Elements + Confirms roles and responsibilities of team members + Discusses case with surgeons orTask  Planning and preparing colleaguesManagement  Prioritising + Considers requirements of others  Providing and maintaining standards before acting + Co-operates with others to achieve  Identifying and utilising resources goalsTeam  Co-ordinating activities with team members Example behaviours forWorking  Exchanging information good practice  Using authority and assertiveness  Assessing capabilities  Supporting others Example behaviours for poor practiceSituation  Gathering information − Reduces level of monitoring becauseAwareness  Recognising and understanding of distractions  Anticipating − Responds to individual cues withoutDecision  Identifying options confirmation − Does not alter physical layout ofMaking  Balancing risks and selecting options  Re-evaluating workspace to improve data visibility − Does not ask questions to orient self to situation during hand-over
    16. 16. Taking a human factors approach A healthcare example?
    17. 17. Human Factors‘about making it easier to do the right job’ Martin Bromiley
    18. 18. Human factors training should be incorporated as a core skill? 20%• Strongly Agree 20%• Agree 20%• Neutral 20% 0 of• Disagree 100 20%• Strongly Disagree