Jump to content
  • Posts

  • Joined

  • Last visited




4 Novice

Profile Information

  • First name
  • Last name
  • Country
    United Kingdom

About me

  • About me
    Human Factors and Forensics Lead
  • Organisation
    User Perspective Ltd
  • Role

Recent Profile Visitors

The recent visitors block is disabled and is not being shown to other users.

  1. Content Article
    Continuing the 'Why investigate' series, in this blog, Martin Langham looks at collecting data, introduces the idea of measurement, and asks what published science is there for testing it ‘beyond reasonable doubt’.
  2. Content Article
    In Part 8 of the 'Why investigate' blog series, Martin Langham takes a look at the hub's error trap gallery and explains why when we conclude it's an error trap we are missing the bigger picture.
  3. Content Article
    In part 1 of my blog series, I said "This will be a series of short blogs that will cover the investigation process, answer questions about humans, and shine a light on the method of forensic investigations”. It is time to answer some questions
  4. Community Post
    Hi Keith – all good stuff and all classic Cognitive Psychology (CP) and Human Factors (HF). Nice to read an email not about team work, non-technical skills or crew resource nonsense. Might be worth a chat at some point? Some thoughts... A lot of the thinking and deciding experiments are those done in a lab and generalising them to a specific incident is a bit difficult. Where medicine is at the very beginning of CP HF journey. Looking at 50 different biases in environments that are poorly designed with lots of bespoke untested equipment may be good – but most likely for our grandchildren. Simple questions first. Is the equipment usable, does the system of working prevent error, is the human working within the limits of evolution? Excellent point on what you call habitual decisions – or automaticity or automation as we call it. Think about driving a car – all (mainly) automatic decisions as we have not evolved to deal with that amount of information in such a dynamic environment. I'm planning a blog on Situational and Spatial awareness, but those in the military that have been on my course comment- “You science types can't even agree how to measure it”. There are differences in team and individual SA worthy of note. I think in medicine the question to start with is “Who is in my team” There are lots of models and methods of investigation. I’m trained in some of them but if they can be generalised to medicine, well answers below.
  5. Content Article
    Part 6 of this series of blogs about human factors and investigations in healthcare discusses the 'How' and the 'Why'. How did the person die or was injured is different from understanding why it happened? At first this appears to be a pedantic, minor issue, but, as (hopefully) we shall see from this blog, it’s a vital distinction. Question How did the plane crash? Answer It was hit by a missile. Question Why was a missile launched, is a vastly different question. Question How was it that the pedestrian was hit by the car? Answer It was due to the driver not seeing them – but why did they not see them is the question.  Without the why – you can’t do the intervention. Most investigations done stop at the how – few get to the why, especially in medicine, especially with root cause analysis.
  6. Content Article
    This is part 5 of a series of blogs about human factors and investigations in healthcare. The theme is ‘when’ and that covers ‘when’ to investigate and ‘when’ to try any remedies or interventions your investigation data suggests might prevent the incident occurring again. As this blog can be explained by a photo and a graph, we have some time to recap the story so far and, perhaps, predict a bit of the future. 
  7. Content Article Comment
    Well done for highlighting the issue. There is always a reluctance of humans to report things that are “not right”, and lots of my research has been about getting people to report incidents (accidents, near misses, security concerns). If things are not reported all that lovely data (evidence) that could be used for change is not available. No data = No appropriate change. The biggest barrier to reporting is feedback, and what our – oh dear – many, many studies show is that unless the feedback is immediate, appropriate, and the input appears valued, then people don’t report. Part of that feedback, in the longer term ,is evidence of change – or explanations of why things have not changed. Our work in getting people to report issues as soon as they see them is extensive. While success brings a warm glow to us science types – often many thousand percent increase in data in some cases, this can cause an issue possibly relevant to healthcare. I recall a heated debate where the number of incidents reported in a domain rose from 7 per month to over 300. The client was not happy – incidents, they said in a loud voice, have increased massively and we did not pay you to increase the number of accidents! Being a science type, I explained that the number of incidents was the same, you just know about them now. It took a lot of time for them to understand the difference. Simply, No reports, No data, No science, No change. You also highlight that the investigation was not immediate – so I’ll get the ‘When to investigate' blog done soon. I’ll also do something on getting people to report. Again – excellent post, if you see it, say it, and keep saying it until its sorted. Your Human Factors community are there to support you. If someone gives you "it’s a governance issue" or even worse this is "root cause analysis", "it takes time" or "t’s a process", or you "lack the training" then simply ask – what’s my motivation to report another similar incident that’s occurs a few days later?
  8. Content Article
    In my previous blogs I described the investigation process and where facts come from. We also pre-empted the content in this blog by saying that human factors (HF) is the scientific study of humans done by science types. It’s now time to talk ‘people’.
  9. Community Post
    Being the hub HF and investigations topic lead I would say… “What’s not working, and why do you suspect that to be the case?” I would take three or four investigations from last year and see if the interventions worked, or if the report was read, or if anyone still smiles at you! Revisit the four incidents and see if the system fails to safe, equipment is usable, and patients are now safe. Remember the only reason to do an investigation is to stop it occurring again. If the report is only used to keep a door open and nothing has changed – well let’s do something different. You may have thought – we do Root Cause Analysis (RCA) and after a good talking to ourselves we realise its nonsense. Indeed, you are correct. RCA is only now found in medicine and it’s what a management consultant tells professionals to do. I keep referring in my blogs to Prof Wiki. Breaking my rule to undergraduates that it’s to be treated with caution, to postgraduates that its not to be used, and to post-docs well you should be cast out and your slide rule broken over someone’s knee. But when it comes to RCA the Prof is correct there are lots of problems with it. RCA never delivers solutions and its pretty pointless. The idea of a graph with more dimensions than a science fiction novel is not good. I’ve done a bit in medicine and I was asked what I thought – just before a person went on a course. I enquired after what she thought of her week long indoctrination. After short pause she described it as like ‘Postcoital depression’. Although it appeared to be a good idea, it did not deliver, had no future use or potential, and a single method and outcome is just mad. As an engineer, I did not know about such medical conditions, indeed none of my partners did – honestly, no complaints in writing, but Prof Wiki description of that does sound like RCA. When you look at why interventions did not work, think about who investigated, where the facts came from and why you did it in the first place. Perhaps share with others on the forum an investigation and if it did or did not deliver.
  10. Content Article
    This is part three of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’. It concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types was introduced. That facts are best collected by a minimum of two investigators. Pictures being our friend, and the cognitive interview concept was introduced. This part focuses on ‘Who’ should investigate and deals with the experience and expertise of the team, their roles and responsibilities in the light of the facts they will collect.  This blog is aimed at individual trusts and organisations rather than regulators/national bodies, etc.
  11. Content Article
    This is part two of a series about the investigation process and human factors in healthcare. Part one looked at the why we investigate an ‘incident’ and concluded that there is only one reason to investigate – and that’s to stop the error occurring again. The idea that human factors is a science – done by science types rather than by (deep breath) public speakers, non-technical skills (NTS) professionals, those who create team talks, medics who have been on a course about being nice and polite to other medics, and those that have married a human therefore they must be qualified to talk about humans – was also discussed. This and the next blog will introduce the concept of where facts or data comes from. Later blogs will deal with the who, how, when etc. The ‘who’ investigates (next blog) really is determined by where the facts come from. Later – if the cake lasts – we can chat about what to do with the data, and how to report it and save lives.
  12. Content Article
    After completing nearly 600 investigations and research projects in human factors, it might be worth sharing some observations of why we do incident (forensic) investigations. This will be a series of short blogs that will cover the investigation process, answer questions about humans and shine a light on the method of forensic investigations.  This will be undertaken alternating with the topic of human factors – the most misunderstood bit of science the healthcare sector deals with. In these posts I’ll cover what human is, the limits of human performance – covering the senses, fatigue – and why pilots and CRM is very dangerous to healthcare. Above all I want to get the idea that human factors is a science and it’s about understanding how human limits restrict how we deal with the built environment and complex systems.
  • Create New...