Patient Safety Spotlight interview with Laura Pickup and Suzy Broadbent from the Healthcare Safety Investigation Branch (HSIB)

Summary

This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. Laura and Suzy talk to us about the importance of embedding human factors in the design of healthcare systems and tools, the importance of equipping staff to think about system safety, and their work to establish a nationwide conversation about the impact of fatigue.

About the Author

Laura Pickup originally qualified as a chartered physiotherapist and went on to work in the NHS. She later completed a PhD in human factors and worked in academia delivering research and consultancy to various industries. In the last ten years she has worked for healthcare trusts, a medical device company and universities on complex healthcare safety problems, looking at how systems may influence organisational performance, patient and staff safety. She has taught for several universities in the field of healthcare human factors and has worked as a national healthcare investigator and educator. She is a Fellow of the Chartered Institute of Ergonomics and Human Factors.

Suzy Broadbent is a Fellow of the Chartered Institute of Ergonomics and Human Factors with twenty years’ experience in the defence, rail and healthcare industries. She started her human factors career in the rail industry and from there she moved to BAE Systems Air in Lancashire where she became Human Factors Lead on cockpit upgrade programmes. In 2021, Suzy moved into the healthcare sector and became a National Investigator with the Healthcare Safety Investigation Branch (HSIB). She now works as an independent human factors specialist with particular interest in cognitive workload and human-machine interface design.

Questions & Answers

Hi Laura and Suzy. Please can you tell us who you are and what you do?

Laura: I’m Laura Pickup and I’m part of the Healthcare Safety Investigation Branch education team, having formerly been a HSIB National Investigator.

Suzy: And I’m Suzy Broadbent, one of the National Investigators at HSIB.

How did you first become interested in patient safety?

Laura: I fell into it a bit by accident! I originally qualified as a physiotherapist and found myself working in the Department of Ergonomics set up by Sue Hignett, which was the first human factors department in healthcare in the UK. The work really fascinated me and I ended up doing a masters and PhD in Human Factors in 2006. When I came to look for a job, I realised that human factors roles didn’t really exist in healthcare, so I started working in the transport industry. I always wanted to move back into healthcare; as a clinician I’d had experience of trying to work in systems that didn’t allow you to do your job properly. A few years ago I noticed that the science of human factors was beginning to get a voice in the area of patient safety, so I started working back in healthcare in 2015.

Suzy: I got into human factors after my psychology degree, where I was taught by Jim Reason of “Swiss Cheese Model” fame. I went on to do a masters and then ended up working in the rail industry for three years. I then spent 15 years working in military aviation, designing cockpits according to human factors principles to try and prevent errors. I joined HSIB just over a year ago when they started to advertise more human factors jobs in patient safety.

Which part of your role do you find the most fulfilling?

Laura: Both of us have a lot of experience in other industries, so we know the power of human factors, having seen it embedded in those industries. Human factors is still a relatively new concept in healthcare, and while we can’t just ‘lift and shift’, we can bring good knowledge, insights and practice that have worked in other industries. I’m excited that human factors is beginning to have a serious foothold in healthcare, and that’s really changed over the last eight years. We now need to build capacity and expertise in human factors in healthcare—being involved in the education programme at HSIB is a great opportunity to do that and I feel we are now starting to reach the audience we need to.

Suzy: For me, the best part of the national investigator job is going out and talking to people. HSIB do their investigations without attributing blame, we’re just trying to understand what factors led to people making the decisions they made at the time. It can be really reassuring for people when they begin to understand how they were set up to fail by the system. You can almost see a weight being lifted.

The conversations we have as part of our investigations seem to stay with clinicians on the frontline and they start to become more aware of human factors thinking. One doctor I was speaking with about poor packaging design now keeps sending me more examples of packaging error traps he is coming across! It’s really rewarding to know that we are gradually increasing the number of people who are equipped and attuned to thinking about system safety.

What patient safety challenges do you see at the moment?

Laura: I’ve noticed that healthcare professionals tend to blame themselves when something goes wrong: “I should have read that label more carefully,” or “I should have worked around the slow computer system.” There’s a big challenge in trying to shift people’s thinking to focus on designing equipment and processes that focus on usability. Any piece of kit that comes through the door of a healthcare organisation should be considered in terms of its usability and how it might affect the likelihood of an error being made. It needs to be tested by the end users before a decision is made to buy it, and it needs to be properly risk assessed. We’re getting there, but that focus on user-centred design isn’t quite there like it is in other industries.

Another huge challenge is the retention and wellbeing of staff. We need staff to come to work and function effectively, both physically and mentally. So we have to start that conversation around managing the risk and that’s what we hope to do with our work on the issue of fatigue. How can we ensure workplaces support staff to ensure and enable safety?

Suzy: One of the key challenges I have seen, coming from another industry, is how normalised some issues are in healthcare. It’s just expected that computer systems won’t work or that doctors are tired. We know from the science of human factors that these issues are more likely to cause an adverse event, but in healthcare they are just accepted as the norm. Staff often feel there’s no point in asking, challenging or reporting problems because they just need to ‘get on with it’.

Most of the human factors roles in healthcare are investigative roles, but I think we need to see more proactive roles being created to help us design things better in the first place, focusing on our user group and the specific factors they will experience. There’s a reason air traffic controllers have short periods working with breaks in between—it's not possible to maintain such a heightened level of attention for long periods. No human can fully concentrate 100% of the time, so we need to think about the tasks healthcare staff will carry out and try to design out error traps at every stage.

Can you tell us a bit about your work around fatigue in healthcare?

Laura: What we see at the moment is that fatigue and shift patterns are not really considered in safety investigations, but we know from our work in other industries that these factors can contribute significantly to adverse events. Fatigue is just not being reported—as Suzy said, it’s accepted as the norm. 

A group of us from HSIB are working with some clinical colleagues to try and move that conversation forward and highlight that every other investigation body focuses on fatigue and other factors affecting a human’s ability to perform. We’ve taken questions from scientific evidence and colleagues in other industries and have used them to create a Fatigue Trigger Tool to support investigators when they go out on national investigations. 

There is a real challenge around asking questions about fatigue; as they are focused on the individual, staff can be fearful that their answers will be linked to their fitness to practise. The wider issue is that individuals can see it purely as their responsibility to turn up for a shift not tired and able to function well, but we know that the organisation and larger system play key roles in how likely you are to be tired, to be working reasonable-length shifts and to have access to rest spaces and times. So we’re very cautious about how we ask these questions and how we report on them—any reporting has to be about the system, not the individual. 

We have an online event on 17 March which we will follow up with a small workshop, to see whether we can take this conversation to a different level of the healthcare system. 

Suzy: It’s been really interesting using the tool as there was a push-back against these questions initially. But I’m now finding that staff are keen to tell me about the fact they have worked too many shifts in a row, or that it took them 40 minutes to find a car parking space, or that they have to stay an extra hour every shift to complete paperwork. This information is so helpful for us as it starts to build up a picture of the culture. If we don’t ask these questions and gain that understanding, we’re missing a big piece of the jigsaw as to how we can prevent incidents going forward.

We’re also trying to be pragmatic about our approach; we know we can’t fix the issue of fatigue overnight. It’s widely acknowledged that large numbers of NHS staff are very tired at the moment, but there are small interventions you can introduce to mitigate the associated risks. Even acknowledging your fatigue and the impact it might have can cause you to add in extra checks and balances—I’ve spoken to nurses who describe the extra steps they will take to ensure they are making the right decision if it’s 2am and they are very tired. But that’s not to say it’s all on the individual—if hospitals aren’t providing coffee, hot meals and bright lights, they are setting staff up to fail. The science is there to show that these kinds of interventions are essential, particularly during night shifts.

Laura: Like Suzy said, we know we can’t reach the ‘ideal’ in healthcare at the moment, but we’re also keen to showcase that the same has been true in other industries and they have made incremental changes over many years to improve safety. After the Clapham Junction rail crash in 1988, rail companies were required to set limits around shift patterns, but they couldn’t immediately implement the ideal solution to optimise human performance. Instead they worked towards this over 20 years. 

What do you think the next few years hold for patient safety?

Laura: I’m hoping that safety science will have a bigger seat at the table in every organisation. We’re seeking to professionalise the role of human factors in healthcare and want to see patient safety roles well established and held by people with rigorous education in human factors and risk management. Most importantly, we need people who understand how to implement change.

Suzy: When I worked in defence, each manufacturer would have an equivalent post to mine, so when I recommended a change, I could work alongside that contact to push it through. I find that I make recommendations in my HSIB national investigations and am looking around for the human factors person at the other end to ‘catch’ and implement them. Often there is no one, or it's unclear who’s role it is to pick recommendations up. For example, we recently made a recommendation about changing the format of maternity notes—who do we hand that to to design? Having said that, we are seeing more medical device manufacturers creating human factors roles, which is a positive sign. 

At the moment, the MHRA guidance on human factors is not mandatory. When I worked in defence, human factors was mandated from the outset of design processes, and I think that’s where we need to get to in healthcare. Safety in aviation didn’t improve just because they had an investigation board, it improved because safety science and human factors were made integral to the design of equipment, processes and systems.

If you could change one thing in the healthcare system right now to improve patient safety, what would it be?

Laura: Healthcare staff are so keen to do their job well, and so often their work environment is the factor that hinders them from doing this. I would put a mandate in place to ensure all equipment that staff use at work is fit for purpose and designed to help them succeed in their roles.

Suzy: If I had a magic wand, staffing levels would be what I’d fix. That’s numbers, but also ensuring staff have all the appropriate training and tools they need to do their job well.

Are there things that you do outside of your role which have made you think differently about patient safety?

Laura: I have a daughter with a disability, so I feel like I’m also on the other side of the healthcare system. I’m passionate about trying to make sure people are heard; my experience is that it's not always as easy to be heard as a patient or family member. But I think HSIB is good at that, trying to capture the voice of people who have experienced issues with care, and treating their voice as equal to those in the system.

Suzy: Human factors is very much a way of thinking, so it’s not just the day job, we’re thinking about it all the time! I enjoy boxing and often think about the importance of healthcare staff being able to let off steam and exercise during and between shifts.

You can read a wealth of research and resources about fatigue in healthcare and its impact on patient safety on the hub.