From the 5365 operations, 188 adverse events were recorded. Of these, 106 adverse events (56.4%) were due to human error, of which cognitive error accounted for 99 of 192 human performance deficiencies (51.6%). These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
The aim of this study, published in Human Factors journal, was to examine the effects of interruptions and retention interval on prospective memory for deferred tasks in simulated air traffic control. This can be translated into a healthcare environment.
This issue of Hindsight includes articles on:
Malicious compliance by Sidney Dekker
Can we ever imagine how work is done? by Erik Hollnagel
Safety is in the eye of the beholder by Florence-Marie Jegoux, Ludovic Mieusset and Sébastien Follet
I wouldn't have done what they did by Martin Bromiley
The operating theatre works daily by the premise of ‘surgical precision’. Every opportunity to work as a holistic team is embraced, not only as an effective way to get things done, but also as a way to maximise patient safety and reduce risk.
Given the intensity of the work and the mandatory desire for a good outcome, surgeons, anaesthetists, nurses and theatre technicians are embracing a new concept in operating theatre team dynamics. The concept has been developed by nurses at Geelong Hospital. John Gibbs, a Clinical Nurse Specialist in Anaesthetics, studied Crew Resource Management str
The book blends literature on the nature of practice with diverse and eclectic reflections from experience in a range of contexts, from healthcare to agriculture. It explores what helps and what hinders the achievement of the core goals of human factors and ergonomics (HF/E): improved system performance and human wellbeing. The book should be of interest to current HF/E practitioners, future HF/E practitioners, allied practitioners, HF/E advocates and ambassadors, researchers, policy makers and regulators, and clients of HF/E services and products.
Walking by is not what I want to do but walking by is what I do on a regular basis. I am ashamed to write this, to think this, to do this. I don’t think I am alone as I have seen others do it too.
We are not bad people, but I can’t help but think that we have turned into bad nurses. The last thing I wanted to be was a bad nurse.
This was never the plan… it’s crept in, without me knowing it was happening. Until now. How has this happened? How have I become the nurse I despise?
I work on an acute medical admissions unit. We have patients that are admitted from the emergency depa
This short video shows how Brighton and Sussex University Hospitals NHS Trust has transformed the way that handover is received. By using a simple checklist along with a process, the critically unwell patient can be handed over quickly and safely.
Further reading attached:
Standard Operating Procedure for ICU/HDU Handover
South East Coast Critical Care Network Critical Care Intrahospital Transfer form
Key learning points
Two approaches to the problem of human fallibility exist: the person and the system approaches.
The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness.
The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects.
High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that v