Factoring the human into Patient Safety

Factoring the Human into Patient Safety Rhona Flin, Industrial Psychology Research Centre Patient Safety Research Group IV Conferencia International de Seguridad del Paciente Madrid, 25 November 2008

Welcome to the Industrial Psychology Research Centre. The centre specialises in the application of psychology to high reliability workplaces. The group has worked with the oil industry since 1986, and regularly engage in consultancy projects. We are currently working with the offshore oil industry, civil aviation, nuclear power generation, surgery, emergency services, conventional power generation and transportation. Interests of the centre include: •Accident analysis •Incident command •Occupational stress •Emergency decision making •Crew Resource Management •Measuring and managing safety culture/climate •Human factors aspects of safety management and emergency response Clients include: Agip, AKER, AMEC, Amerada Hess, AMOCO, British Energy, BHP, BP, Brown & Root, Chevron, Civil Aviation Authority, Coflexip Stena, Conoco, Defence Evaluation and Research Agency (DERA), EC (DGTREN), First Group, Halliburton, Health & Safety Executive, KBR, Kerr McGee, Morgan Stanley, National Power, NHS, Novartis, Powergen, Royal College of Surgeons, Salamis SGB, Schlumberger, SCPMDE, Shell, Talisman, Texaco, Total, Transocean,, UBS Warburg & UK Nuclear Imc.

www.spsrn.ac.uk

Human Factors “Human factors refer to environmental, organisational and job factors, and human and individual characteristics which influence behaviour at work in a way which can affect health and safety.” Health and Safety Executive (1999) Reducing Error and Influencing Behaviour www.hse.gov.uk/humanfactors

Human variability: Two aspects (Reason, 2000) Human as Human as hazard hero • Slips • Adjustments • Lapses • Compensations • Mistakes • Recoveries • Violations • Improvisations

Safe and Efficient Performance Individual actions Latent Conditions Professional Behaviour Organisational /Professional Job Technical & Culture Performance Non-Tech. Skills A B c

ABC • A – antecedents eg organisational culture – Norms of behaviour • B – behaviour • C – consequences – reinforcement – Rewards or punishments for particular behaviours by supervisors, peers etc, builds culture

Organisational Safety Technical Factors Accident Causation Culture/ Human Worker = Manager + Factors Behaviour Behaviour

The complexity of hospital cultures a) ‘A confusion of languages’ b)Who are the leaders? nominal leaders e.g. Management but powerful informal leaders e.g. Consultants

Safety culture and behaviour • Worksites with more positive safety culture show lower accident rates • Workers who perceive their supervisors/ managers to be more committed to safety engage in more safety-related behaviours and fewer risk taking behaviours • Motivational mechanism linking culture to behaviour – expectations/ rewards linked to behaviour of managers/ supervisors (Zohar, 2002) ( Landy & Conte 2006)

Safety culture questionnaires

Safety Culture Dimensions • Prioritisation of Safety (production vs. safety) • Management commitment to safety Safety systems, training, communication, resources, incident reporting systems, feedback, accident analysis, teamwork, organisational support etc etc

Key worker safety behaviours Speaking up about safety Reporting incidents Participation in safety activities Rule compliance/ Risk taking

Leadership Style for Safety? Transformational leadership (Bass) is the strongest predictor of safety in industry (Flin & Yule, 2004, Quality & Safety in Healthcare)

How do Senior Managers foster an unsafe culture? • Sending the wrong signals by their: – language – behaviour – priorities – time allocation • Upward appraisal of senior managers’ safety leadership (e.g. healthcare CEOs)

Changing the culture • Clarify priorities • Provide safety resources (inc. time) • Reward appropriate behaviours • National initiatives (Government driven) • Licensing and revalidation • Patient safety education for healthcare students • Training safer behaviours (non-technical skills)

Tenerife (1977) Two Boeing 747s crashed into each other on the runway. 583 people killed. Causes: conflict resolution, assertiveness, communication, situation awareness, stress – non-technical skills

Human Performance Limitations Training • Understanding of physiological and psychological factors influencing task performance –eg stress, fatigue, work conditions • Pilots trained at ab-initio stage • Pilots have to pass an exam in this • No evidence of this type of training in Medical Schools

Pilots’ Non-Technical Skills • Term non-technical skills first used in European civil aviation. • ‘Cognitive and social skills of flight crew members in the cockpit, not directly related to aircraft control, system management, and standard operating procedures’. • NOTECHS – is a taxonomy and behaviour rating system for pilots’ non-technical skills developed in Europe Flin et al (2003) Development of the NOTECHS system for assessing pilots’ CRM skills. Human Factors and Aerospace Safety, 3, 95-117.

Generic Non-Technical Skills • Leadership • Team Work / workload management • Communication • Situation Awareness • Decision Making • Personal Limitations – managing stress and fatigue

Clinical Human Factors Group www.chfg.org

Non-Technical skills, error and adverse events Identify Non- Technical Skills Error Poor Non- Unsafe Increased chance Technical Skills behaviours Train and assess using Adverse event ANTS/ NOTSS etc Safer Good Non- behaviours Decreased chance Observation, rating Technical Skills Avoid/ and feedback Capture Error using behavioural rating system

Anaesthetists’, Surgeons’ and Scrub Nurses’ Non-Technical Skills University of Aberdeen, NHS Education Scotland, Royal College of Surgeons of Edinburgh

Anaesthetists’ Non-Technical Skills ANTS Task Team Situation Decision Management Working Awareness Making Planning & preparing Category Prioritising Element Providing & Behaviour maintaining standards Identifying & utilising Checks equipment, prepares drugs for the case resources

Non-technical skills taxonomies Surgeons: www.abdn.ac.uk/iprc/notss/ Anaesthetists: www.abdn.ac.uk/iprc/ants/ Nurses: email: l.mitchell@abdn.ac.uk Project sponsors: Royal College of Surgeons of Edinburgh (RCSEd) NHS Education for Scotland (NES)

Patient Safety Education • Medical Schools (eg Aberdeen) – Year 5 module on patient safety – Year 1 survey of knowledge/attitudes to patient safety • WHO patient safety curriculum: medical students (for 2008) • Canada: Patient Safety Competencies (for 2008) • Australia: Patient Safety Education Framework (2005) – www.patientsafety.org.au • MSc Patient Safety (Imperial; Aberdeen) – Clinicians and healthcare managers

Further information • r.flin@abdn.ac.uk • www.abdn.ac.uk/iprc lists of projects and papers and reports Scottish Patient Safety Research Network www.spsrn.ac.uk

Factoring the human into Patient Safety

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