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  • Observational tools, Human Factors and patient safety: a recent discussion at the Patient Safety Management Network

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    A strong focus on systems thinking and an encouragement to apply insights and expertise from human factors and ergonomics is paramount in how we plan, design and deliver healthcare safely. It’s central to the WHO Global Patient Safety Action Plan, the NHS Patient Safety Strategy, new Patient Safety Incident Response Framework (PSIRF) guidance on how to investigate incidents of unsafe care and the National Patient Safety Syllabus.[1-3] It’s something Patient Safety Learning emphasise in our report A Blueprint for Action and is central to the organisational standards for patient safety that we’ve developed.[4]

    But how should we ‘do’ human factors? How do we apply the concepts, methodologies, tools and techniques in healthcare? What training do we need? How can patient safety managers embed human factors in all of their work, not just a reactive response to incidents of harm?

    These are some of the questions that patient safety managers have been asking and discussing in the recent Patient Safety Manager Network (PSMN) meetings. The PSMN is an informal voluntary network for patient safety managers in England. Created by and for patient safety managers it provides a weekly drop-in session with guests to talk through issues of importance, providing information, peer support and safe space for discussion. You can find out more about the network here.


    Claire Cox, one of the PSMN founders, took the bull by the horns and shared with us a fascinating insight into how she’s been applying the Systems Engineering Initiative for Patient Safety (SEIPS) model in her role as Patient Safety Lead (clinical) at King’s College London. Claire was looking for an observational tool but wasn’t quite sure the best way to apply it (as she’d never had any formal training).

    What is the SEIPS model?

    “The SEIPS model is a theoretical model rooted in human-centred systems engineering or ‘human factors/ergonomics’. All versions of the model depict three major components, the work system, processes and outcomes; key characteristics or factors of each; and how the components affect one another.”[5]

    Developed by Professor Pascale Carayon and colleagues in the University of Wisconsin, the model attempts to convey a highly complex interacting environment and its related system outcomes.

    Using the SEIPS model

    Claire discussed and sought permission from the ward manager to observe practice on a ward that was seen to have a few problems. The ward manager was delighted with the offer of support and was reassured by Claire that the outcomes wouldn’t be shared with anyone until the manager had signed it off.

    Claire wasn’t looking to address a specific issue, but just wanted to observe the ward in a structured way to help her understand how the ward worked, how staff undertook their tasks, whether there were easier ways for staff to do their work, and whether there were hazards that might lead to error and avoidable harm. Using the NHSE Real Time Observational Toolkit’, Claire layered this over the SEIPS model, adding in her evaluation and recommendations, which would later become an action plan developed with the manager and the team being observed.

    Claire gained much insight from the structured observation and learnt a lot, observing:

    • How the ward rounds were undertaken.
    • The workarounds that staff were taking to compensate for an unhelpful physical environment.
    • The risk assessments that staff were having to make – for example, balancing patient fall risks with risks of access to medication.
    • Safety of medication and availability of locked cupboards.
    • The risk of error and reporting rates; were staff not recognising some of the ‘near misses’ or not reporting them? And why?

    None of this was previously known by the manager and it showed the value of taking staff into your confidence and being able to see how staff were managing the best they could.

    This really was ‘work as done’ territory; judgements that staff were making in real time, without refence to policies and procedures, as a consequence of there being too few staff resources.[6] The ward was short of a ‘housekeeper’, so a healthcare assistant (HCA) was covering that work leaving the nurse without HCA support. This was ”rubber hits the road”, where corners were being cut and judgements were being made to minimise risk to the patients and maintain the level of efficiency required. This was really enlightening in the context of understanding ‘work as done’ not the ‘work as imagined’ as described by Dr Steven Shorrock.[7]

    Next steps

    Following the observations, Claire tweeted and spoke to people. But what next? Should she jump in with a solution? Healthcare workers are trained to be good at seeing problems and finding solutions, but are they always the right solutions that address the underlying causes of error and harm?

    So that kicked off a great practical discussions on the topic. The PSMN meeting had a number of patient safety managers who are experts in or studying human factors in healthcare, through Healthcare Safety Investigation Branch (HSIB) training and at MSc level. We were also joined by an expert in the field, Professor Bryn Baxendale, Chair of the Health Education England Simulation Advisory and Development Committee. Issues that were discussed included:

    • Clinical staff have a clear understanding of the complexity of healthcare. Observations of ‘work as done’ with a structed tool can help identify the detailed nature of this: the basic tasks of a ward round, how staff relate to each other, how the unspoken rules and assumptions inform decisions.
    • How SEIPS can be used as a broad observation tool that helps identify risk, which can then help to focus on the biggest risk and drill down in more detail: to follow the Desmond Tutu quote, “there is only one way to eat an elephant, a bite at a time”.
    • The need to have a healthy level of inquisition; being curious is so important. Why are people doing it in the way they’re doing it?
    • Don’t need to know it all but need to be interested and intrigued; my superpower is ‘what is that’.
    • Different people will observe different things, based on their professional background (clinical/non-clinical) and training.
    • Don’t rush to conclusions.
    • Capture mismatches between workload and capacity.
    • Observe how staff are adapting to get the job done, with the best of intentions.
    • Important to gauge the context: environment, resources etc.
    • SEIPS can help to identify an enormous volume of stuff; then use other tools to manage risks, identify threats and hazards, identify consequences and control mechanisms; e.g. 'Bowtie analysis' – which is used in many high hazard industries as a means of identifying and understanding how risks of major incidents are managed and controlled.[8]
    • How to take the output of an observation study forward?
    • Important to involve the ward team; they might not know they’re doing what they’re doing and they should be involved and be part of the solution.
    • No action plan should be developed until we better know the problem.

    A few patient safety managers immediately wanted to see the template that Claire had used to try it themselves. She has kindly shared it in the attachment below.

    Everyone agreed that the session was fantastic. But how to take forward? More tools are needed but we need to work through and support each other in their application; this shouldn’t be a ‘tick box exercise.’ A few patient safety managers agreed that they’d work together to:

    • Develop the observational tool.
    • Provide a user guide for patient safety managers.
    • Seek out experts like Bryn, Paul Bowie and Mark Sujan to guide this work.
    • Consider how we bring patients in; how can their observations be captured.
    • Share experiences of applying other methods e.g. After Action Reviews, Debriefs.

    We also discussed creating a list of patient safety managers, with skills and experiences so that others’ could reach out when they need help and advice. Claire called this patient safety Tinder!

    Watch this space. There’s more to come and if you want to be part of some work in this area, just let us know. Email: claire.cox11@nhs.net


    1. World Health Organization. Global Patient Safety Action Plan 2021-2030; 3 August 2021.
    2. NHS England and NHS Improvement. The NHS Patient Safety Strategy; 2019.
    3. NHS England and NHS Improvement. Patient Safety Incident Response Framework, Last Accessed 5 March 2022.
    4. Patient Safety Learning. The Patient-Safe Future: A Blueprint for Action; 2019.
    5. Holden R, Carayon P. SEIPS 101 and seven simple SEIPs tools. BMJ Quality & Safety; 20 October 2021.
    6. Hollnagel E. Can we ever imagine how work is done?; 2017.
    7. Shorrock S. Proxies for Work-as-Done: 1. Work-as-Imagined; 28 October 2020.
    8. McLeod R, Russell W, Stewart M, et al. Preliminary case report study of training and support needed to conduct bowtie analysis in healthcare. BMJ Open Quality; 2021.


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