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Showing results for tags 'Human factors'.
Found 550 results
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Content ArticleIt's important to think about how we are safe on the front line, doing the work day in and day out. How do our policies, processes and practices across an entire organisation impact the safety of our work? Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives. He currently specialises as a human factors and safety specialist in air traffic control in Europe, but has worked across most safety critical sectors. In this podcast, from the East of England Ambulance Service (EEAST) General Broadcast, Steven talks about how policies can interfere with each other, how hierarchy impacts performance and reflects on incidents.
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Content ArticleIn this blog, Steven Shorrock reflects on why are we so resistant to change.
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Content ArticleIn any attempt to understand or intervene in the design and conduct of work, we can consider several kinds of ‘work’. In practically all attempts at understanding and intervention, however, we are not considering actual purposeful activity – work-as-done. Rather, we use proxies for work-as-done as the basis for understanding and intervention.
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Content ArticleDr Maryanne Mariyaselvam, doctoral researcher in patient safety at Cambridge University, and Dr Peter Young, consultant in anaesthetisa and critical care at Queen Elizabeth NHS Trust, King’s Lynn, on how human factors thinking and design enabled two new patient safety innovations.
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Content ArticleOptimising patient safety is a goal of healthcare. Much has been spoken and written about it, and it is well established as a core activity for all those working in healthcare systems. This has not always been the case; historically, error and harm from healthcare was an accepted risk of treatment. However, as standards of treatment and care have improved this acceptability was questioned and refuted, and the patient safety movement born. This article, published in Anaesthesia, summarises the evolution of safety science, describing historical approaches, comparing them with recent concepts in safety, and describing how they affect staff working within the healthcare system.
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Content ArticleIn his latest blog, Steven Shorrock explores what humanistic values and human decency means in management and organisational behaviour. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content ArticleAs an industry, biopharmaceuticals is immature when it comes to the integration of human performance into operations. This article from BioPhorum aims to accelerate the industry’s maturity by building a greater understanding of what is desired and explaining how to get there. Human performance is believed by many companies in the biopharmaceutical industry to be a focus on human error reduction, where work outcomes will improve by adding more requirements and coercing people to try harder to be infallible. This archaic approach is not sustainable today and is not human performance. The environment that we operate within – both externally and internally – is changing and yet we are still applying decades-old mental models of what good problem solving looks like, and how this drives overall performance and results. Human performance is the way to make a shift towards systems thinking. Without making this change, organisations will continue to stagnate and actually be unable to keep up with the increasing complexity of the environments they work in, and the environments they create. This blue-sky vision of human performance takes time and patience to properly implement and must be viewed as a fundamental change to how an entire organisation executes work. Essentially, this is a transformation of the organisation’s systems and thinking over a period of several years. This article provides guidance that has worked within the biopharmaceutical industry and the unique regulatory space it operates within.
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Content ArticleBC PSLS met with Wrae Hill, Human Factors and System Safety, Interior Health (IH), to discuss medication error traps. They use the example of an anaesthetist who, during an emergency C-section, under time constraint, gave their patient the drug cisatracurium instead of succinylcholine. Both medications are used for muscle relaxation and paralysis, however cisatracurium has a much longer duration of action. Cisatracurium was available in the Labour and Delivery Suite, but the vial cap of cisatracurium had previously been blue, yet today it was red. This ‘medication error trap’ – a recurrent situation that predictably snares a large number of different people – resulted in the patient having to be ventilated for longer than anticipated.
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Content ArticleWhen things go wrong, we seem to display a reliable tendency to do one thing: blame those at the ‘sharp end’. No matter how complex the system, how uncertain the situation, or how inadequate the conditions, our attention post-accident seems to turn to those proximal to the consequence, whom we judge to have failed to control the hazard in question. The notion of ‘just culture’ has developed over the past decade or so in response to this and is highly valued by front line staff. Just culture is, however, borne of the Safety-I mindset. Since the advent of ‘just culture’, the Safety-II perspective has emerged. Safety-II defines safety not as avoiding that things go wrong but as ensuring that things go right. Safety-II views the human not as a hazard, but as a resource necessary for system flexibility and resilience. In light of this, it has been proposed that the idea of just culture should be abandoned. If we take a Safety-II view, ‘just culture’ might indeed seem unnecessary. Steve Shorrock explores this further in his latest blog.
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Content ArticleWork-as-disclosed is what we say or write about work, and how we talk or write about it, either casually or more formally. Work is disclosed by many people, both those who do the work, and those who do not, based on more or less knowledge of work-as-done. Work-as-disclosed will tend to be different to work-as-done in several ways and for several reasons, including lack of knowledge about the work, difficulties in communicating about the work (e.g., the technical details), or fear about the consequences of disclosure. In this blog, Steven Shorrock explains three spaces for work-as-disclosed that are relevant to trying to reduce the gap between work-as-disclosed and work-as-done, or at least to understand why such a gap exists.
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Content ArticleHealthcare practitioners, patient safety leaders, educators and researchers increasingly recognise the value of human factors/ergonomics and make use of the discipline's person-centred models of sociotechnical systems. This paper from Holden et al. first reviews one of the most widely used healthcare human factors systems models, the Systems Engineering Initiative for Patient Safety (SEIPS) model, and then introduces an extended model, ‘SEIPS 2.0’. SEIPS 2.0 incorporates three novel concepts into the original model: configuration, engagement and adaptation. The concept of configuration highlights the dynamic, hierarchical and interactive properties of sociotechnical systems, making it possible to depict how health-related performance is shaped at ‘a moment in time’. Engagement conveys that various individuals and teams can perform health-related activities separately and collaboratively. Engaged individuals often include patients, family caregivers and other non-professionals. Adaptation is introduced as a feedback mechanism that explains how dynamic systems evolve in planned and unplanned ways. Key implications and future directions for human factors research in healthcare are discussed.
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Content ArticleTo find out how checklists and monitoring work in actual practice, Benjamin and Dismukes observed line operations during 60 flights conducted by three air carriers from two countries. They used a structured technique to observe and record checklist and monitoring performance, and situational factors that might affect performance. Because an important function of checklists and monitoring is to catch, or “trap,” operational errors, they also recorded deviations in aircraft control, navigation, communication and planning. When a deviation was observed, they tracked whether crewmembers identified and corrected it, and whether there were any consequences that might affect the outcome of the flight. They found that checklists and monitoring are not as effective as generally assumed.
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Content Article
An encounter with an error trap by Steve Highley (6 August 2015)
Sam posted an article in Error traps
Steve Highley looks at responding positively to error using a personal experience involving his car and highlights how to find and deal with error traps. -
Content ArticleIn these presentation slides, Paul Gantt and Ron Gantt, Safety Compliance Management, discuss human error and its effect on occupational safety. They identify the role of error traps in human error, how an organisation can identify and eliminate error traps to prevent incidents and they review case studies involving human error.
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Content ArticleDo you ever see someone trapped into making a human error? Bad human engineering caused an error likely situation. Perhaps there was a precursor to the error – somethings that could be recognised?
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Content Article
The human error trap (7 June 2017)
Patient Safety Learning posted an article in Error traps
Phillip Ragain, director of training and human performance at The RAD Group, explains why it wrong to focus on human error when an incidence occurs. A majority of incident investigations correctly identify employees who made mistakes or deviated from policies and procedures, but this distracts from other causal factors and preclude better corrective actions. In his blog, Philip discusses how leaders can avoid the human error trap. -
Content ArticleAll human activity, along with associated emergent problematic situations and opportunities, is embedded in context. The ‘context’ is, however, a a melange of different contexts. In our attempts at understanding and intervening, rarely do we spend much time trying to understand context, especially as it applies to the current situation, and how history has influenced where we are. Instead, we tend to: a) make assumptions about context, but not make these explicit, resulting in different unspoken and untested assumptions; b) limit contextual analysis to proximal, ‘obvious’ or uncontroversial aspects; or c) jump to a potential solution (or a way to realise an opportunity), shortly followed by planning for this intervention (which has the important function of helping us to feel in control, thus relieving our anxiety – at least temporarily). An approach Steven Shorrock has found useful is to spend time considering contextual influences (e.g., on decision making, at multiple levels of organisations) on problematic situations or potential solutions, more explicitly. He shares this in his latest blog.
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Content ArticleThis blog discusses how competition can help drive improvement up to a point, but after which it may perpetuate unnecessary harm. It gives examples of where competition can become unhealthy. A more constructive approach requires collaboration focusing on patients to ensure they receive the best possible care.
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Content ArticleHuman factors affect paramedic practice and training. However, although there are frequent references to human factors in the literature, little evidence on this is available on those that influence student paramedic development. In this article, published by the Journal of Paramedic Practice, looks at a case study which highlighted certain human factors unique to the role, most notably how interactions between students and mentors can affect a student's practice. Following this, the awareness and effect of human factors within the student paramedic role were investigated.
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Content ArticleThe NHS Patient Safety Strategy requires every Trust to have a Patient Safety Specialist: an evolving role with the purpose of ensuring that “systems thinking, human factors and just culture principles are embedded in all patient safety activity”. Patient safety is a big topic, and apart from a general sense of frustration that we don’t seem to be making any progress, there’s little agreement about what the problems are, let alone the solutions. Q member, John Tansley discusses his philosophy of patient safety through four key icons, and reflects on how this can inform and shape the evolving role of Patient Safety Specialists.
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Content ArticleHuman factors is a scientific discipline which is used to understand the interacting elements and design of a complex system, aimed at improving system performance and optimising human well-being. This book brings together a range of specialist authors to explore some of the key concepts of human factors related to the field of paramedic practice. The system elements of paramedic practice can include the patient, the paramedic and their colleagues, the environment, the equipment, the tasks, and the processes and procedures of the organisation. The relationships between these components are explored in detail through chapters which cover ‘human error’, systems thinking, human-centred design, interaction with the patient, non-technical skills of individuals and teams, well-being of the paramedic, safety culture and learning from events. This helpful and informative guide provides frontline paramedics and ambulance clinicians with practical advice and knowledge of human factors that will be helpful in supporting safe and effective practice for all involved. It will also be of interest to pre-hospital care professionals who are involved in education, learning from events, procurement and influencing safety culture. Above all, it shows how an understanding and application of human factors principles can enhance system performance and well-being, and ultimately lead to safer patient care.
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Content ArticleEach quarter, the Patient Safety Movement Foundation hosts a free webinar to address a central patient safety topic. This virtual workshop session on the importance of human factors and systems safety focuses on re-designing work as opposed to re-designing the human who does the work. Incorporating a human factors and systems safety approach allows for the development and integration of knowledge, skills and attitudes that facilitate successful performance at the front lines of care. Healthcare leaders will learn how to apply human factors and systems safety concepts to understand true hazards in their organizations while fostering a culture of safety.
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Content ArticleHuman factors is a critical component of future aviation success in both military and civil aviation systems, especially where it concerns safety. This white paper from the Chartered Institute of Ergonomics and Human Factors contains the visions of 15 ‘thought leaders’, showing how they believe aviation evolution will unfold between now and 2050, and the critical role of human factors in ensuring system performance and safety. The thoughts in this paper can be applied to human factors in health and social care.
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Content ArticleThis blog from the PatientSafe Network discusses cognitive dissonance. Cognitive dissonance — the pain of accepting ego-dystonic facts — mitigates against an open, rational aggressive cycle of process improvement. Unfortunately the hierarchical structures in healthcare mean we are likely to suffer from this. Those further up, best positioned to bring about positive change, are the most likely to suffer cognitive dissonance.
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Content ArticleHow many times have you tried to plug a USB in the wrong way round? Since both sides are usually similar on the outside, chances are that you have tried to force a USB in upside down at least once. The consequences of this mistake are usually negligible, but in healthcare, poor design can have serious repercussions. We all know how to plug in a flash drive, so why do we still slip up? Usually, it’s because we are concentrating on something more important. Imagine the same happening in a busy emergency unit where healthcare providers are carrying out life-saving procedures. They’re short on time and working under pressure. One of the paramedics is trying to resuscitate a patient who just went into cardiac arrest — he charges the defibrillator, presses “on”, but instead of shocking, the device switches off, causing the team to waste precious time. What went wrong? And how could the same issue be prevented in the future? Neil Ballinger, head of EMEA at manufacturing parts supplier EU Automation, explains the role of human factors engineering in optimising medical devices.
