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HUMAN FACTORS Chris Mowatt
HUMAN FACTORS
Situational Awareness
Cognitive skills
Leadership/followship
PATIENT SAFETY
SITUATIONAL AWARENESS
SEEING THE WOOD FOR THE
TREES
SITUATIONAL AWARENESS
Knowing whats going on around you……
What can impact that?
Have you had any experiences that are relevant?
COGNITIVE SKILLS
PATIENT SAFETY
Provision of highest quality care with 100% reliability
HOW DO WE GET THEREHigh reliability
organisations
Design work to make
error impossible
Develop teamwork and
communications
Human Factors Science
HOW DOES YOUR BRAIN WORK
Analytic Automatic
DOES FREE WILL EVEN EXIST?
AUTOMATIC VS. ANALYTIC
The centipede was happy—quite!
Until the toad in fun Said “Pray,
which leg comes after which?”
Which brought his mind to such a
pitch
He lay distracted in a ditch
Considering how to run.
Property Automatic Analytic
Reasoning style Intuitive, heuristic Conscious, deductive,
abstract
Working memory Not involved Involved
Awareness Low High
Automaticity High Low
Speed Fast Slow
Effort Minimal Considerable
Vulnerability to bias Yes Less so
Reliability Low, variable High, consistent
TWO BASIC THEMES
Teamwork and comms
 Crew resource management
Systems redesign
 Lean
 Simple – shortest route
 Kaizen – spirit of continuous improvement
TEAMWORK TRAINING
Team dynamics
Mental models
Situational awareness
“Red Flags”
Personal style
Briefing and debriefing
Attitudes and behaviours
HEURISTICS
Name of heuristic Characteristic
Availability Something that recently occurred comes
to mind quicker
Anchoiring Persist despite evidence to the contrary
Confirmation Actively seek evidence to support your
position
Representative Decisions based on what’s typical
Premature closing Stop before information verified
Sutton’s slip Going for the obvious without
considering alternative possibilities.
HEURISTICS
Good
 Fast
 ‘Easy’
Bad
 Omission
 Commission
 Substitution
HEURISTICS
What stops you thinking analytically?
 Tiredness/fatigue
 Distraction
 Emotional distress
 Interruption
CONFIRMATION BIAS
What’s the rule
Just goes up
FIXATION BIAS
#susanalbumpar
ty
OPERATION ORCADIAN
Bronchospasm?
Something else?
ANALYTIC COGNITION
Flexible
 Doesn’t rely on short cuts
 Don’t need to recognise patterns
Hard work
 New tasks
 Slow, single channel that requires all our concentration
 FIXATION
UNCONSCIOUS PROCESSING
Processing power is finite
Mind operates to relieve tension and seek pleasure
LEADERSHIP
Bystander effect
 Heard of it?
 Take ownership
 Individualise
Ringelman effect
 1888 Tug of war
 Managing big groups
Speak up
 Say what you see……
OVER TO YOU
Design a system to make your working life safer.
What are the key elements?
How do you embed them?
Can you think of any examples?
HUMAN FACTORS
STOP 10 seconds for 10 minutes
Hierachy - FLAT
Concurrent hindsight
Pre test probability
Practice medicine in the light not the dark
SBAR

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Human factors