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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 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 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 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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EventAimed at clinicians and managers, this national conference will provide a practical guide to human factors in healthcare, and how a human factors approach can improve patient care, quality, process and safety. You will have the opportunity to network with colleagues who are working to embed a human factors approach, self-assess and reflect on your own practice and gain CPD accreditation points contributing to professional development and revalidation evidence. Book your place or email kerry@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org to receive the discount code. Follow the conference on Twitter #HumanFactors
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Content ArticleA short article from NHS Education for Scotland about Significant event analysis (SEA). Enhanced SEA is a well-established safety improvement tool in general practice. However, there is good evidence to suggest that many SEAs are poorly conducted by practice teams, leading to missed opportunities to make health care safer.
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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 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 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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News ArticleAn external review has been launched at a leading children’s hospital after a series of “never events”. According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month. Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data. In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient. Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process." “The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.” Read full story (paywalled) Source: HSJ, 24 September 2020
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Content ArticleHuman performance is cited as a causal factor in the majority of aircraft accidents. This manual addressed various aspects of Human Factors and its impact on flight safety but many of the principles will be relevant to healthcare also.
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Content ArticleA report from MedStar Health National Center for Human Factors in Healthcare on the work and research they do in human factors.
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Content ArticleInsight into medical device and system failure and the teachings of Henry Petroski, a professor of civil engineering at Duke University, who wrote about failure analysis and design theory.
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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 ArticleThe COVID-19 pandemic has had one of the biggest effects on work-as-done in healthcare in living memory. So what might we learn about work from the perspectives of frontline workers? Steven Shorrock asked a variety of practitioners to give a short answer – whatever came to mind. The themes that emerge centre around people, their activities, their contexts, and their tools. Many insights concerned the varieties of human work, goal conflicts, design, training, communication, teamwork, social capital, leadership, organisational hierarchy, problem solving and innovation, and – generally – change. Steven Shorrock is an interdisciplinary humanistic, systems and design practitioner interested in human work from multiple perspectives.
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Content ArticleMersey Care NHS Foundation Trust is committed to delivering perfect care but this depends on the development of a just and learning culture.
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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 ArticleProgress enables the creation of more automated and intelligent machines with increasing abilities that open up new roles between humans and machines. Only with a proper design for the resulting cooperative human–machine systems, these advances will make our lives easier, safer and enjoyable rather than harder and miserable. Starting from examples of natural cooperative systems, the paper from Flemisch et al. investigates four cornerstone concepts for the design of such systems: ability, authority, control and responsibility, as well as their relationship to each other and to concepts like levels of automation and autonomy.
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Content ArticleIn 2008, the National Patient Safety Agency (NPSA) issued a Rapid Response Report concerning problems with infusions and sampling from arterial lines. The risk of blood sample contamination from glucose‐containing arterial line infusions was highlighted and changes in arterial line management were recommended. Despite this guidance, errors with arterial line infusions remain common. Gupta and Cook report a case of severe hypoglycaemia and neuroglycopenia caused by glucose contamination of arterial line blood samples. This case occurred despite the implementation of the practice changes recommended in the 2008 NPSA alert. They report an analysis of the factors contributing to this incident using the Yorkshire Contributory Factors Framework. They discuss the nature of the errors that occurred and list the consequent changes in practice implemented in their unit to prevent recurrence of this incident, which go well beyond those recommended by the NPSA in 2008.
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Content ArticleThe theme of this Issue of Hindsight is ‘Wellbeing’, which has an undeniable link to safe operations, though this is not often spoken about. This Issue coincides with the COVID-19 pandemic. The authors of the articles in this Issue were considering wellbeing in the context of aviation, and other industries. But the articles touch on topics that are deeply relevant to the pandemic. The spread of the virus and its effect on our everyday lives has brought the biological, psychological, social, environmental, and economic aspects of wellbeing into clear view in a way we have never seen before.
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Content ArticleThis National Patient Safety Agency (NPSA) booklet presents information concerning how better design can be used to make the dispensing process safer in community pharmacies, dispensing doctor practices and hospital pharmacies. There are a number of new factors that will impact on the dispensing process, such as: electronic prescription services; auto-id and automation technologies; more responsibilities for pharmacy technicians; and enhanced pharmacy services. These factors have been incorporated into these safer design recommendations Organisations, managers and healthcare workers involved in dispensing medicines should use this booklet as a resource to help introduce new initiatives to further minimise harms from medicines.
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Content ArticleCalls to integrate human factors and ergonomics (HFE) within healthcare and patient safety have become increasingly frequent in the last few years.This editorial from Waterson and Catchpole decscribes some of the misconceptions and misunderstandings that sometimes surround HFE.
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Content ArticleThis guide from RSSB povides a practical illustration of how fatigue risks can be systematically managed to improve the health and safety of the workforce and operations. Although for the rail industry, it can be applied to other organisations. It sets out key elements of effective fatigue management and illustrates how these can be incorporated into a company's overarching safety management arrangements.
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Content ArticleThe Medicines and Healthcare products Regulatory Agency issued this guidance following recent cases, including cases with fatal outcomes, in which patients have received the wrong medicine due to confusion between similarly named or sounding brand or generic names.
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Content ArticleThe existence of confusing drug names is one of the most common causes of medication error and is of concern worldwide. With tens of thousands of drugs currently on the market, the potential for error due to confusing drug names is significant. This includes nonproprietary names and proprietary (brand or trade-marked) names. Many drug names look or sound like other drug names. Contributing to this confusion are illegible handwriting, incomplete knowledge of drug names, newly available products, similar packaging or labelling, similar clinical use, similar strengths, dosage forms, frequency of administration, and the failure of manufacturers and regulatory authorities to recognise the potential for error and to conduct rigorous risk assessments for nonproprietary and brand names, prior to approving new product names This article from the WHO Collaborating Centre for Patient Safety Solutions looks at the issues and suggests actions.
