MartinL

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.

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.