Human error is as old as humankind itself and widely recognised as a significant cause of mistakes. Much of the research in this area has originated from high-risk organisations (HROs), including commercial aviation, where even simple mistakes can be catastrophic. A failure to understand and recognise how Human Factors (HF), especially those that affect performance and team working, can contribute or lead to serious medical error is still widespread across healthcare. Sadly, this commonly occurs in the operating theatre, one of the most dangerous places in hospital.
While attitudes and acceptance of pre-surgery briefings has improved using the World Health Service (WHO) Surgical Checklist, this does not address other 'personal' factors that can lead to error, including stress, fatigue, emotional status, hunger and situational awareness.
Following initial work around HF perception amongst operating theatre teams, Peter Brennan's (student at the University of Portsmouth) research has lead to significant delivery changes to the high stakes Membership of the Royal College of Surgeons (MRCS) examination, taken by up tp 6,500 junior doctors per year. After recognising boredom and fatigue in examiners, further published studies found an improvement in examiner morale with no significant changes in exam reliability or overall candidate outcome. These changes have improved patient safety at a National level. Other high stakes National Events have been evaluated where repetitive assessment occurs during long days, providing reassurance to organisers and the General Medical Council.
28 HF-related publications have been included in this work, including several reviews of important personal factors that affect performance and how these can be optimised at work.