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The attached report summarises the event. Morning presentations included a keynote address from Professor Coleman, University of Birmingham, and a moving and inspiring presentation from Lisa Richards-Everton, a Patient Safety Campaigner. Delegates then participated in a taster workshop looking at challenges around labelling and used the SIEPS 2.0 model to conduct a systems analysis of the management of a patient’s condition. The afternoon branched into parallel syndicate workshops with the first workshop focusing on training and education around labelling; what challenges needed addressing with training, and how a human factors approach could optimally start to address these training issues. The second workshop looked to identify and discuss challenges around the medicine label and how these could be addressed using a human factors approach. This included looking at some of the issues that exist with current labelling design, before discussing what information is necessary and then providing recommendations for the design from a human factor’s perspective. All syndicate groups gave recommendations for next steps to address these challenges, which were shared at the conclusion of the meeting. Several delegates then volunteered to be involved in a steering team, whose remit would be to address the identified challenges by exploring ways in which these systembased recommendations might be implemented. Recommendations around training perspectives included areas such as education and communication; system redesign, use of technology and recommendations about the design of medical packaging with a human factors approach.

The guide recommends seven key steps: Establish a COVID-19 response team.Understand how the virus is transmitted. Carry out a risk assessment. Engage staff. Encourage behavioural change.Implement risk control measures. Monitor, review and learn.

Let's start with a summary of where we are in the blogs. I’m told our reader likes the summary (a Mrs Trellis of North Wales). In part one we decided why we investigate an incident and what an incident was. In part two we decided that two investigators (or more) collect facts together in a more accurate way than one would. In part three we gazed into each other’s eyes and concluded that facts are our friends and where they might come from. We decided interviews and photos give us good facts. In part four we were introduced to what human factors is, and what it is all about and how western psychology is about exploiting the worker! In part five we thought that facts are time dependent and men of my age should not wear shorts outside a restaurant/come damaged aircraft. We discussed how dependent witness memories are on the elapsed time for the effective retrieval of information. These blogs, therefore, are asking simple investigation questions of Who, What, When and Why, and basic questions about what can humans do (human factors). So here we are back to the powerful question ‘Why’ but this time, rather than "why investigate an event?", we are asking "why did this event happen?". Most investigations stop at the point of understanding how the person was injured or died. The how they died does not give you enough data to prevent it occurring again. Knowing, for example, that an elderly, lone rail passenger unfamiliar with the station died from head injuries after falling on a platform with the investigation team concluding that ‘they lost their balance and fell backwards’ does not help understand why this happened or how to prevent its reoccurrence. Why did it occur that day, to that person, on that platform? Might an intervention based on the question ‘How’ be that no one over 60, who is unfamiliar with the station and travelling alone, be prohibited from travel. The important question is why and not how. Likewise, a pedestrian is found dead by the side of the road after a collision with a van. How did they die? Well head trauma after collision with a van. How did that occur? The driver said that at night it was too dark to see the running pedestrian. Indeed, at the reconstruction it was very dark. But after 25 questions of ‘why’ came the critical ones. Why was a person out running in near total darkness without a light? Why could the van driver not see them? Why was there no light (torch etc) found with the pedestrian so they could run without falling into the numerous pot holes? Why that van and why that pedestrian. The why (in this case) comes from human factors research into perceptual thresholds of how much light needs to hit the retina for the cognitive process to start. Long story, but the answer to why was a murder disguised as a traffic accident. Which takes us back to my first blog – what’s an accident – this was not a rare random event with multiple causes. It had one cause – top tip sleeping with a colleague’s partner is not a good idea. Unless you answer why, then there is no intervention and that ‘why’ is ‘why’ we do this. Becoming a 5-year-old The skill of an investigator in human factors is to keep asking the question Why (and perhaps not to insist an infographic is needed). Like my 5-year-old self. Why can’t I ride my bike to the next town… But why, but why. The police car brought me back last time – I was not lost. This may explain why a disproportionate number of my friends are clinical psychologists! Case studies Two case studies. Let’s stick to rail. I can do why are anaesthetics rooms so small, but I’ll get all emotional! If I’m found dead in an alley it’s a hospital facilities manager wot did it. Case One A train station where there are 17 serious incidents on a single set of steps down to platform 1. It’s a traditional Victorian design urban station with access at street level and platforms below the booking hall. All platforms are connected by a glass overpass. No other platform (there are six) has an issue. One case is a fatality. How did they occur? The answer is – the person fell down the stairs. Head injuries and broken legs (not the same person!) are common. The ‘how ‘is answered. The why is not. Why did they fall down the stairs we asked. “There are stairs and people will fall down them” came the reply. Why? “Well there are stairs and people will fall down them”. But why these stairs, why this platform, and why 17 people? Well, came the reply, we will have to put a poster up telling people ‘these are stairs.’ Why did they fall we asked? We have a poster telling people how not to fall down them and how to use stairs (hold the handrail) they replied. We asked as a five-year-old would – why do you think these people have problems with these stairs? So, let’s think of the why questions after some facts. Might be worth also predicting that posters are the sign of defeat and result from only asking ‘how’. Also, putting posters above stairs, so that people look at them and not the stairs, is another classic failure of understanding human performance. Some facts Timetable information shows platform 1 is the city bound platform. Observations indicate that people descend the stairs very rapidly when there is a train present at the platform. Secondary observations come to understand that running starts at the ticket office overlooking the glass passageway over to the platform. Incident data reveals peak at rush hour above that of exposure (rise in passenger numbers). Only platform 1 can been seen from the walkway and the ticket office. The ‘why’ hypotheses was that as people became aware of the train arriving at the city bound platform, they made a run for it. We interviewed several of those injured. Most common statement from the predominantly local people was “I knew I would miss the train as I could see it at the platform, so I ran”. The remedy was to put plastic obscuring film over the glass walkway so you could not see if a train was at the platform. No cognisance of a train’s presence = no rapid stair descents. Only journeys into the city appear to be highly time dependent. Outcome After 11 years, no incidents on the stairs, no aggression to the ticket office staff (give me my ticket now!) and posters removed. Why – we asked ‘why’ not ‘how’. Removing ‘safety’ posters is always a good idea. I’m still trying to find out what an internal brand consultant is – they were against the removal of posters. Answers if you know what these are and how they make the world better please. Case 2 At a train station, there were 27 falls ‘down the steps’ of which four were citizens from the USA. These citizens of America are after the compensation for ‘foreseeable’ injury in the US courts. Think expensive when compared to compensation claims in the UK. As above, ‘the how’ was they were injured by a fall. Why at this station? Why these people? Some facts Incident data revealed all those falling down the stairs were visitors to the area (based on address supplied). Plans of the Victorian station reveals it’s a small (four platform station) with over 80 different exit route combinations, via three underpasses. Exit here is time-critical – it’s near an airport with a connecting bus. There are over 130 signs containing over 900 words of advice. Observations and interviews showed that perhaps passengers lost spatial and situational awareness (more in later blogs) and became disoriented. CCTV images showed one passenger was walking up and down the platform twice, then walking through one of the underpasses six times, before they injured their arm when the bag got caught in the handrail and they ‘went down, way down, the steps’ ( from Incident report). Our initial hypothesis was that a lost and disoriented passenger with bags will find stairs more of a challenge than one who is not. Remedy We removed most of the signs on the platforms and underpasses and replaced with one type of exit sign. Whether its exit to the airport or exit to the pub it’s still an exit. Locals – not represented at all in the data – know which of the combination of exits will get them to the pub. Outcome No incidents in 12 years, and the platform staff last year took rail executives around ‘their’ station telling them how easy it was to prevent slips, trips and falls because “someone asked why”. Why, and multiple causes Early on in our blog life together we said that accidents have multiple causes. In healthcare we are not sure how many variables there are and even the extent of the problem. We also described that the cause is about the ‘environment’, the ‘human’, the ‘system of working’ or the ‘equipment’. We decided together this determines ‘who should investigate’. Engineering failings are done by engineers, for systems failures investigations by nursing staff are recommended. Well here the ‘Why' word repeated on the first day is the solution to find out who should investigate. When do you know you have possibly stopped asking why too early? The common reasons for stopping asking the question ‘why’ is when you get to one of the following conclusions: 1. Its human error. 2. It’s the person who had the incidents fault – but remember organisations fail not people. If you get these conclusions, keep going and ask your friendly human factors person for help. Remember, one of the limits of investigations is that you can’t ask questions about things you don’t know about – obvious really, but that’s why there should be two of you and perhaps one of those is a human factors person. A major failing in root cause analysis is this fact is always overlooked. 3. I cannot ask ‘why’ anymore without getting asked to leave the building/the NHS/the human race… The solution is to ask questions using the Socratic method. More later when we think about logic – but the Greek philosophy types nailed it many centuries ago (just like they invented human factors in medicine; ergonomics they called it). Citing Professor Wiki once more and to appeal to the midwifes among you, the Socratic method is: “a form of cooperative argumentative dialogue between individuals, based on asking and answering questions to stimulate critical thinking and to draw out ideas and underlying presuppositions. It is named after the Classical Greek philosopher Socrates and is introduced by him in Plato's Theaetetus as midwifery (maieutic) because it is employed to bring out definitions implicit in the interlocutors' beliefs, or to help them further their understanding”. Again, this is part of the human factors persons training and why we ask the questions in the way we do to members of the investigation team (sorry). There is a management consultancy (boo hiss) methodology called the ‘5 why method’, and its creeps into the root cause analysis nonsense (more boos). But just asking why without the Socratic teachings tends to just annoy people. Exploring ‘Why’ as an equal to the person you are talking to is more respectful and gets better data, and you should not get thumped. Who asks why and to whom? In later blogs we shall chat about interviewing witnesses. This blog is about the internal dialogue in the investigation team or, if there is just one of you, the internal monologue. Asking why to a witness is generally not the thing to do. Its common in healthcare but the witness cannot report Why, they only know the How. Witnesses provide facts, the team finds answers from those facts ('Where do facts come from?'). Summary The ‘Why’ word is very powerful when added to a blank sheet of paper and a pen in the hand of the investigator and means that you focus on the outcome and not on a process. As replies to my earlier blogs – about how healthcare is all about process and not outcomes – well one word and some paper mean you can just focus on prevention. And dear reader why we investigate is to prevent it occurring – in the words of Metallica – 'Nothing else matters'. And finally... The station (discussed above) where elderly people represent the dataset. All falling backwards on platform 1 and our initial (yours and mine dear reader) remedy was to exclude over 60s from it unless they were trained. Suggestions of why and what questions would you ask. Comments below. Top tip – no one was running and all very cognisant of the train times, and all but one sober. Happy if you want to test out the Socratic method now. Posters, as a solution, are not permitted. Read Martin's other blogs Why investigate? Part 1 Why investigate? Part 2: Where do facts come from (mummy)? Who should investigate? Part 3 Human factors – the scientific study of man in her built environment. Part 4 When to investigate? Part 5

Currently, as I work from home developing materials for our new PgCert and MSc ‘Human Factors for Patient Safety’ course, I am also, as are many others, watching our current pandemic unfold and reflecting on how this emphasises the importance of such a course for those working within the health and social care sectors. We are living in uncertain times, which for most people is stressful and worrying for many different underlying reasons: loss of income, loss of a job, fear of contracting the illness and the lottery of outcomes, living in isolation or living in crowded homes 24/7, reduced opportunity to exercise, concern for children and other family members and friends, fear of what comes next… to name just a few. As a human factors professional, this comes as no surprise since our job is always to consider the range of human responses and human characteristics in order to identify to what extent it is possible to support this range; and this is indeed happening. For those with mobile phones and internet access, the virtual world is rapidly expanding with new and newly found apps to connect extended families and friends, to undertake virtual meetings, online lessons and assessments, access to art and museums, research opportunities, theatre performances, online exercise classes and increased opportunities to shop. For those without this access the difference is stark. Let’s turn our attention to these apps; someone first has to have the idea and check that there are people out there who would be interested, then there is the need to design the app, and in such a way that we want to use them and can use them. To do this is dependent upon considering the user, i.e. us humans – this is achieved by integrating user-centred design (UX design) and human factors (ergonomics). Turning our attention back to the health and social care sector, we need to consider human factors when assessing the myriad of health apps out there and the increasing use of apps to support our health and social care – from prompting individuals to take their medication to monitoring our health or providing health advice. So what else are we seeing as this pandemic embraces us all? Information is constant, we are truly a connected global society, from daily ministerial briefings to news reports and social media. This provides very public and graphical representations of our human responses – intellectual, emotional, behavioural and physical. For example, we see numbers of confirmed COVID-19 cases and deaths, graphs and charts showing where these are occurring, the age and gender, we see percentages of the population affected BUT to do something about this requires us again to dig deeper. We need to find out the underlying reasons. In the same way, when we respond to patient safety incidents we need to dig deeper and identify the underlying and root causes so that we can truly do something about it. I'd like to provide some examples of how my work in human factors is influencing COVID-19 research and resources. In response to the UK Government asking for businesses to provide thousands of ventilators to help tackle the COVID-19 pandemic, myself and other human factors professionals collaborated with Patient Safety Learning to provide human factors/ergonomics input to support the design effort for these new ventilators. This resulted in a ventilator safety in use driver diagram developed by Patient Safety Learning and a human factors guide from the Chartered Institute of Ergonomics and Human Factors. In addition, in an example of cross-industry collaboration, Yorkshire Water gave me permission to share their human factors engineering specification with designers of ventilators and other critical medical device designers, which quickly took place. Following this, my attention was turned towards sharing advice on working in high heat and heat stress. Based on the Health & Safety Executive Guidance (HSE (2013) INDG451 ‘Heat Stress in the workplace’), I produced a document and flowchart addressing what happens to us when we experience extreme heat, this has been welcomed and shared by the London midwife managers. Next, came questions relating to shift work and fatigue, which led to me creating a summary document based again on a Health Safety Executive website and an ORR document (Office of Rail Regulation [Jan 2012] Managing Rail Staff Fatigue) that emphasises the need for a fatigue management system plus tips for helping ourselves and each other to sleep better when shift working and to recognise and respond to the symptoms of fatigue (www.staffs.ac.uk/clinical-skills). It has also been interesting to note the range of public and enforcement behaviours shown in the media that relate to our response to the ‘lockdown’ in this and other countries. Human responses often link to aspects of culture and sub-cultures, power and influence, personal responsibility and risk perception. All of which are highlighted during our Human Factors for Patient Safety course. Looking ahead, I can see many learning and research opportunities evolving from this pandemic and the opportunity to add to our human factors knowledge base for the good of society. Within the Staffordshire School of Health and Social Care our mix of staff provides us with a unique opportunity to achieve new research in human factors and patient safety and we look forward to embracing the opportunity to learn together.

This document outlines ten key guidance points that designers of procedures should address at all stages of its development, implementation and review: 1. What is a work procedure? 2. Ensure a procedure is needed 3. Involve the whole team 4. Identify the hazards 5. Capture work-as-done 6. Make it easy to follow 7. Test it out 8. Train people 9. Put it into practice 10. Keep it under review. An explanation of the discipline of Human Factors and Ergonomics (HFE) and the sub-discipline of human-centred design are also provided.

This document outlines seven key topics that designers and manufacturers of ventilators should address. Suggestions for how to address these issues and the link to the COVID-19 crisis are identified: User interface Users of ventilators Environment of use Task The risks Instructions for use Training.

Key learning points Education and training of healthcare workers Equip the workforce with the fundamental knowledge and skills of human factors/ergonomics. Support, promote and embed the discipline in the practitioner’s professional training and development. Empower participation in human factor/ergonomic initiatives. Draw on existing expertise. Organisational commitment Comprehensive, resilient, proactive patient safety programme. Safety culture (not punitive to individual). Risk management system. Programme evaluation, meaningful and informative indicators, continuous learning and improvement.

Wrong tooth extraction has been clearly designated as a 'never event' since April 2015. However, in 2016/17, wrong tooth extraction topped the charts as being the most frequently occurring never event based on NHS England’s data. What can we do to mitigate these incidents? Based on both practical experience and research evidence, BAOS advises that the main methods for mitigation of errors are: learning from mistakes – including investigation and root cause analysis engaging the clinical team when developing 'correct site surgery' policies utilising the LocSSIPs template and guidelines from NHS England/RCS England developing a correct site surgery checklist that is appropriate for your clinical environment providing training for staff on the use of the checklist ensuring that the checklist is being used correctly through active audits of the processes involved supporting the clinical team throughout the process and not taking punitive action when incidents do occur.

This paper from the British Medical Journal, describes specific examples of HFE-based interventions for patient safety. Studies show that HFE can be used in a variety of domains.

Key themes: Situational awareness Handover resources Interruptions and distractions Delegation Task-fixation, helicopter view & closed-loop communication Ask for help.

The Authors, conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff well-being. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff well-being.

The museum is curated by Dr. Samuel West, licensed psychologist, PhD in Organisational Psychology.