As humans we are prone to making mistakes and getting things wrong, which is part of our everyday nature. However, in healthcare human errors can often lead to incidents, which can be sources of inconvenience or sometimes major consequences that can directly affect our patients. Human factors theory plays an important role in understanding how human behavior contributes to such errors, through our interaction with colleagues, equipment, systems, and the working environment. The theory forms an integral part of aviation safety and has also found its feet in other industries, including healthcare. This presentation was presented at the Saudi Health 2014 International Nursing Conference and introduced the basic concepts of human factors theory in nursing. Case studies were used as examples to draw on the factors that contribute to issues of care, which directly affect patients. Interventions of how to address common human factors to minimize risks were also discussed.

1. Addressing Human Factors to Minimize
Risk to Patient Safety in Nursing
Waseem Munir RN, BSc (Hons), MSc, RRP

2. Purpose
• Provide an overview of human factors theory and its relevance to
patient safety
• Introduce a basic framework for human factors in healthcare
• Use case studies as examples to show how the framework can be
applied in nursing
• Provide some basic approaches of how human factors can be
addressed by healthcare staff and leaders

3. What are Human Factors?
• Dr Ken Catchpole –
„Human Factors is a scientific discipline not a collection
of factors about humans –
- Which is why we don‟t answer the question
“What are human factors?”‟
„I Like the idea of: “enhancing clinical performance
through an understanding of the effects of teamwork,
tasks, equipment, workspace, culture, organisation on
human behaviour and abilities, and application of that
knowledge in clinical settings.”‟
(chfg, online)

4. What are Human Factors?
• Individual & external factors that may influence behaviour that result
in errors leading to patient harm, for example;
o Individual – Communication between peers, effect of leadership
on subordinates, or stress etc.
o External – Work environment, systems, processes etc.
• Some factors may already be integrated in existing tools (e.g. Heaps
analysis tool – Under „practitioner factors‟)
(chfg, online; Carthey 2013)

5. Human
Factors Model
Direct Factors
Actions or Omissions that
directly affect practice and
our patients
Influencing Factors
Factors that have the
potential to change the
direct factors, to improve
them or make things
worse
Systems & Culture
Factors can be managed
with interventions through
systems and culture
improvements (RCN, 2014)

6. Case Study 1
Temazapam was recently made a controlled drug in a hospital, which
required the drug to be locked away in a cupboard. This needed two
nurses to count the number of tablets and sign a special log book, with
the patients‟ details every time a dose needed administering.
One particular ward had 15 patients requiring Temazapam, which led to
prolonged drug rounds for nurses, particularly as the locked drug
cupboard was located at the end of the ward. The nurses decided to
remove the entire bottle from the cupboard and place it in their pocket
for the round, with the intention of counting the remaining tablets and
completing the log book at the end of the round.
They perceived the controlled drug policy as a means to prevent drug
abuse, rather than preventing risks to patient safety and their new
practice was overlooked by the head nurse. This practice continued for
a while until one day they found that one tablet was missing when the
nurses proceeded with the count and logging the log book at the end of
the round.
Did they loose a tablet or did one of the 15 patients receive an extra
tablet?
(Adapted from: Carthey &
Clarke, 2010)

7. What Human Factors Led to the Error?
• Direct Factors
• Decision to keep the bottle of Temazapam in the
pocket, with the intention of completing log book and
counting tablets at the end of the drug round.
• Influencing Factors
• Stress – Pressure of providing timely medication to
a large number of patients requiring Temazapam.
• Safety Culture – The practice of carrying the bottle
of Temazapam and completing the count/logging
later became the „norm‟ and „accepted‟ amongst
peers.
• Leadership - There needed to be a willingness to
address why the new practice might be a bad idea.
• Environment – Location of the fixed drug cabinet
(Dalton & Moran 2013; RCN 2014)

8. Case Study 2
During a night shift on a 29 bed surgical ward, the shift in charge asked a
float nurse to prepare a heparin infusion for a patient. The ward was very
busy that night with 4 acutely ill patients and 6 more requiring high level
nursing care.
The float nurse was very tired and unfamiliar with the ward or specialty and
also felt rushed in preparing the heparin infusion. The calculation was made
quickly and as the drug was being drawn one of the sickly patients rang the
call bell.
Another nurse who was nearby saw the float nurse leave the prepared
infusion in the medication room, as they attended the call bell. The colleague
asked whether they could help by setting up the infusion, to which the float
nurse replied “No, I need to check it again”.
After attending to the patient the float nurse forgot about the heparin and
around 45mins later remembered and returned to the medication room to find
the infusion had gone, as it was set up by the other nurse. The infusion was
immediately stopped and the dose recalculated, which was found to be
incorrect. Upon asking why the infusion was started, the nurse replied that
“The float nurse had said she had already checked it”. (Adapted from: Carthey &
Clarke, 2010)

9. What Human Factors Led to the Incident?
• Direct Factors
• Distraction from main task of preparing
heparin to answer call bell. Although this may
be important, how well was it managed?
• Loss of awareness, as the float nurse had
forgotten about heparin.
• Dexterity – From the helping nurse miss-
hearing her colleague on whether the infusion
was checked and not ensuring the calculation
was correct before giving the infusion. Float
nurse was also unfamiliar with the ward and
specialty, was there difficulty in caring for the
patient that activated the call bell?
• Influencing Factors
• Fatigue – Tired float nurse could have
contributed to rushing preparation and less
awareness.
• Work environment – The ward was very busy
with highly dependent patients. This factor
could have impacted on the fatigue of the float
nurse, as well as other issues.
• Communication – Lack of clear communication led to
misunderstanding between nurses on whether infusion
was checked.
• Leadership – Where was leadership in this situation?
(LMQ, 2014)

10. Interventions
Immediate
(Incidents)
Continuous
(Managing our risks)

11. Immediate Interventions
• Specific to circumstances or findings identified, for example;
• Case Study 1:
o Providing extra help during drug rounds or allocating controlled-drug administration
to a specific nurse.
o Placing the locked drug cupboard more conveniently, so that there is better
adherence to policies.
• Case Study 2:
o Communication in-service training
o Encourage staff to speak out when feeling overwhelmed with tasks
• Both Case Studies:
o Learning from factors that lead to non-compliance of policies and procedure
o e.g. Lack of staff engagement during policy development, time-pressure, lack of governance.

12. Continuous
Interventions
Human Factors Training
• Help raise awareness
• Mandatory for all staff
• Incorporated into
orientations
• Focus on developing soft-
skills (Communication,
teamwork etc.)
Leadership Walk-round
• Opens channels of
communication
• Demonstrates commitment
• Opportunity to identify
areas for improvement
Integrating Human Factors in
Healthcare System Design
• Considers human factors in the
work environment from outset
• Integration during process
improvement for established
systems
Human Factor Champions
• Can observe existing practice
for development opportunities
• Act as ambassadors for staff to
liaise with confidentially
• Can be created from existing
quality/risk champions
Evaluations
• Safety culture
surveys/assessments that
include human factors
Integrating HF with incident
investigations
• Theory can be used as a
framework for RCA‟s
(Frankel 2004, Carthey 2013, Cavanagh & Hulme 2009)

13. Other Useful Methods & Tools
• Understanding the reasons for non-compliance of policy and
procedures (Immediate & Continuous)
(Carthey, 2013)

14. Other Useful Methods & Tools
• SPLINTS Framework for evaluating non-technical skills, to enhance
healthcare staff skills during surgical procedures
o Situational awareness
o Communication and teamwork
o Task management
(Carthey, 2013)

15. References
• Carthey J. & Clarke J. (2010) Implementing Human Factors in Healthcare: „How to‟ Guide. Patient
Safety First. Available online at:
http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Intervention-
support/Human%20Factors%20How-to%20Guide%20v1.2.pdf
• Carthey J. (2013) Implementing Human Factors in Healthcare – „Taking further steps‟: „How to‟
Guide Volume 2. Clinical Human Factors Group. Available online at: http://www.chfg.org/wp-
content/uploads/2013/05/Implementing-human-factors-in-healthcare-How-to-guide-volume-2-FINAL-
2013_05_16.pdf
• Cavanagh P. & Hulme A. (2009) Leadership for Safety: Supplement 1, Patient Safety Walkrounds.
Patient Safety First. Available online at:
http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/How-to-guides-2008-09-
19/How%20to%20Guide%20for%20Leadership%20WalkRounds%202009_04_07.pdf
• Clinical Human Factors Group Website: http://chfg.org/
• Dalton D. & Moran S. (2013) Human Factors and Safety Culture in Healthcare. The Health
Foundation. Available online at:
http://patientsafety.health.org.uk/sites/default/files/resources/human_factors_and_safety_culture_in_
healthcare.pdf

16. • Frankel A. (2004) Patient Safety Leadership Walkrounds. Institute for Healthcare Improvement.
Available online at:
http://www.ihi.org/resources/Pages/Tools/PatientSafetyLeadershipWalkRounds.aspx
• LMQ (2014) The LMQ Human Factors Model [Online] available at: http://aviation.lmq.co.uk/human-
factors/
• Royal College of Nursing (2014) Human Factors – What are they? [Online] available at:
http://www.rcn.org.uk/development/practice/patient_safety/human_factors_-_what_are_they
sa.linkedin.com/in/wmunir/