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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

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.

Recently Dr Peter Brennan tweeted a video of a plane landing at Heathrow airport during Storm Dennis. I looked at this with emotion, and with hundreds of in-flight safety information, human factors, communication and interpersonal skills running through my head. I thought of the pilot and his crew, the cabin crew attendants and the passengers, and how scared and worried they would have felt. On a flight, the attendants will take us through the safety procedures before take off. We are all guilty, I am sure, of partly listening because it is routine and we have heard it all before. Then suddenly we are in the midst of a violent storm and we need to utilise that information! We ardently listen to the attendants instructions and pray for the captain to land the plane safely, which he does with great skill! I now want to link this scenario to the care of our patients in the operating theatre. They are also on a journey to a destination of a safe recovery and they depend on the consultants and the team to get them there safely. Despite being routine, we need to do all the safety checks for each patient and follow the WHO Surgical Safety Checklist as it is written: ask all the questions, involve all members of the surgical team, even do the fire risk assessment score if it is implemented in your theatre. The pilot of that flight during Storm Dennis certainly did not think he was on a routine flight. He had a huge responsibility for the lives of his crew and many passengers! We can only operate on one patient at a time. Always remember, even though the operation may be routine for us, it may be the first time for the patient – so let's make it a safe journey for each patient. Do it right all the time!

To use the tool, you just need to enter your height and weight into the online calculator, along with your height and weight 3-6 months ago. You will be given a rating that will tell you if you are at high, medium or low risk of malnutrition. You will then be able to download a dietary advice sheet that gives basic information and suggestions for improving nutritional intake. If you are worried about your weight or having difficulty eating, make sure you talk to your GP or a healthcare professional. The dietary advice sheet was developed in partnership with a number of professional organisations. NB this site is intended for adult self-screening only.

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.

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

What can I learn? Managing human failures Staffing Fatigue and shiftwork Safety critical communications Human factors in design Procedures Competence Organisational change Organisational culture Maintenance, inspection and testing

The high complexity model is intended for services that have more complex pathways e.g. chronic (more than one year) services in acute, mental health or community services, where patients may return for several follow up appointments at intervals which may change depending on how their condition progresses. You can use this model to inform decision making and planning, in supporting delivery of timely care to patients. This web page includes the following tools: high complexity model user guidance demand and capacity: high complexity model (blank) demand and capacity: high complexity model (populated).

I work in, both, the work imagined and prescribed, but practice in the world of work done. It’s interesting working in both worlds and has made me ask these questions: Why this happens? What are the consequences? How can we manage this disconnect? Real-life scenario What happened? A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery. The nurse prints off the policy for placing an NGT from the Trust's infonet. The nurse inserts the NGT and checks the policy on how to test if it is in the correct position. The tube could be in the stomach (the right place) or it could be placed in the lungs (not a great place for medicines and feed to go!). The nurse calls the nurse in charge for support. It’s been a long time since she has placed an NGT and she wants to check she iss doing the right thing. The senior nurse arrives, before the feed is commenced. The senior nurse notices that the policy that the nurse is using is out of date. Checking the position of NGTs had changed. The senior nurse prints out the updated policy – NGT was in the correct position. This was a near miss event. So what? If an NGT is in the lung and you give medication and liquid feed there is a high chance the patient would contract fatal pneumonia at worst or a protracted stay on the intensive care unit on a ventilator at best. In both these cases, it would need to be declared to the regulators as they are classed as serious incidents. What next? This incident was one of many near misses that were collected over four shifts. This incident was discussed with the Deputy Chief of safety within that Trust. His first reaction was: "When was this? We had a Datix last year of the same incident – why has this happened again and why don’t I know?" It was true, there were a few similar incidents last year and an action plan was put in place to mitigate another incident like this happening again. All the old policies were to be removed from the infonet and replaced with the updated versions. Not only this, the Trust was now moving towards a web-based search facility that enables the clinician to have all the updated evidence for policies, antibiotic therapies, prompt charts, documentation and prescribing advice. The guide would be updated and the old policies would automatically be replaced, thus mitigating clinicians using out of date policies and procedures. The document management system was put in place to ensure it is easier to do the right thing. So, if this forcible function was in place, how did this incident happen again? Not all staff know about the new document system. Some nurses think this search facility is for doctors only. Nurses are prohibited to use their mobile phones on the ward. Clinicians not always able to get to a computer. It takes too long to update when opening the browser – therefore people are using it offline. The final point is an interesting one. Making it easy to do the right thing is one of a number of aspects that a safe system is comprised of; however, if part of that system i.e. the Wifi is not set up to support the change, that system is at risk of a ‘work around’. Work arounds are what healthcare staff do to enable them to get through that shift without immediate detriment to themselves or the patient, make swift complex decisions easily and to ‘tick the box’. Time is a precious commodity, especially when you are a frontline worker. We know the document management system will have the updated policy; we wait for the download. We wait. We wait a bit longer. Eventually it loads. Remembering it takes a long time, we save it and use it ‘offline’ for future access. By using the guide offline makes it quick and easy. We are using Trust policy; however, that policy may now be out of date. So what? Implementation of this online guide was made to make our lives easier and safer for patients and ourselves. Due to an oversight of how clinicians ‘actually’ use and interact with this change in the work environment, it could have an adverse outcome for patients. How would the safety team know this was happening? Near misses seldom get reported. Chance meetings in corridors, chance conversations overheard, a reliance on staff that may know the answer – if we ‘fixed’ the problem for that near miss, why should we report it? No harm came to the patient after all. We have a good culture of reporting in the Trust; however, our safety team are overwhelmed with incidents to investigate. The current system is set up to investigate when harm has happened rather than seeking out ways to prevent harm. I’m part of the problem, so I can be part of the solution? I would welcome any support on this. Does anyone have any solutions or strategies in place where frontline staff are involved in the reporting of near miss events and are part of the solution to mitigate them?

Movies from 1939 are engrained in American culture. They share narrative, characters and quotes that people are aware of even if they, alas, haven’t seen the films. The list of films produced in what some consider the finest year in Hollywood history speaks for itself; it includes Stagecoach, Ninotchka, Destry Rides Again, Mr Smith Goes to Washington, The Wizard of Oz and both my and the Academy’s favourite, capping the impressive output with a December 1939 release, Gone with the Wind. While recognising that certain characterisations in these movies haven’t aged well, the films have made an indelible mark on Hollywood history. The films of 1939 laid the groundwork for great things to come. They launched the careers of artists that have made a cultural mark worldwide: need I say more than John Wayne or Judy Garland? Another capstone to a productive year is the end of the 20th year post the publication of To Err in Human. The widely influential 1999 US publication showed us how to fight for patient safety – our Tara. It outlined approaches to address the seemingly reoccurring tornadoes in healthcare built to instead point toward home – a safe health system. Scarlett’s tenacity, her force of personal will and sustained belief in Tara is what pulled her through the maelstroms of civil war Georgia. Clinicians, however, cannot rely on grit and willpower alone to address clinical and organisational threats to safety. The lack of control to minimise systemic pressures on their moral imperative to do a job well in non-supportive situations reduces a clinician’s ability to practice safely. Building on the To Err is Human legacy, The US National Academy of Medicine (NAM) is committed to understanding factors that contribute to unsafe care. A NAM recent report on burnout lays out a system-focus strategy for organisations to reduce conditions that degrade physician health and, thus, safe practice. Dorothy’s quest to return home energised her instead to engage a multidisciplinary team. The skills of Scarecrow, Tin Man, Cowardly Lion and, yes, even Toto got them through the forest to safety. Without their individual commitment to the mission, humanness and competence the team would have never gotten to Oz. The American Association of Medical Colleges (AMMC) recently released a set of competencies expected in physicians to support quality practice. By suggesting what educators embed in their training efforts, the AAMC helps ensure learning opportunities that build competencies are embedded in programmes on the yellow brick road to safe care provision. Transparency helps us to see situations as they really are. Peaking behind the curtain enables exploration that, if used appropriately, can drive improvement. Toto pulled back the curtain to expose a threat that, once clarified, launched a collaboration that got Dorothy back to Kansas. The US-based Leapfrog Group has also forged a partnership to look behind the curtain. The latest release of the Hospital Safety Score data has focused attention on what isn’t working to support safety while celebrating hospitals that demonstrate sustained safety and quality. The scores track weaknesses in hand hygiene, infection control, and patient falls as elements of whether a hospital is safe. There have been challenges: wicked witches, budget constraints, refusal to accept change and conflicts. It has not been an easy road to Tara since Err is Human was released. Experts in the field have shared their dismay in the lack of progress. Yet stories of resilience, partnership and teamwork continue to motivate the resolve of Dorothy and Scarlett to keep going. Goal-focused efforts can backfire and not live up to their expected purpose. The South didn’t win the Civil war though they believed it was their destiny to do so. Scarlett never won back Ashely no matter how hard she tried. A recent article published in Health Affairs highlights the lack of correlation between the US Medicare and Medicaid programme reimbursement initiative and direct impact on patient safety in the state of Michigan. Its impact is questionable—which for a large-scale solution embedded throughout the system—is humbling. Questionable actions can be a human reaction to stress that needs to be called out and managed to reduce their presence and impact. While centering her as a force for action, Scarlett’s spoiled and selfish behaviour also destroyed her most meaningful relationship. Such destructive behaviours degrade relationships needed for the safety of care. A large US study published in NEJM found that harassment and inappropriate behaviours effect one-third of general surgery residents surveyed, particularly women. The mistreatment and bias generated by both patients/families and medical team members were identified as a key factor in burnout and physician suicide. The stories from great films of 1939 illustrate the power of grit, resolve, focus and leadership as elements of achievement. They share with us memorable characters that live with us long after the movie theatre lights come up. Through the embodiment of the tenacity of Scarlett and the team-focus of Dorothy we can and will work through the known barriers to reduce patient harm due to medical care. We have not yet arrived at Tara, but we continue to work tomorrow toward getting over the rainbow.

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