How many times have you been to the drug cupboard/trolley at work and looked at it with despair?
How many times have you looked at a written prescription or plan of care and were unable to read the writing?
How many times have you gone into the storeroom and spent ages looking for what you want as everything looks the same or it has moved to a different spot?
These are what we call error traps. It is as if you have an annoying brother/sister that is trying to catch you out! Sometimes in healthcare, no matter where you work, there are times when it is not easy to do the right thing. Often, we know about these traps and have become used to living with them. We may set up processes that mitigate us making the mistake.
This is great, but is this addressing the problem? We have diagnosed the problem, but we haven’t stopped that potential error from happening again.
In the world of ergonomics it is the forcing function commonly cited in human factors case studies as recommendations for error-prevention in health and safety contexts. It means forcing users to do something in a certain way in order to proceed on a journey.
A great example is how banks have prevented customers from leaving their card in the ATM. The forcing function is that the machine will bleep to prompt the customer to remove the card from the machine before the money is released. This prevents cards being left in the machine. Whereas if there was just a sign saying ‘remember to take your card’ there will always be a risk that people will not read the sign – the sign may fall off or be removed or it will become invisible as people rush about in their daily lives.
So how can we solve these error traps in health and social care? We have created an error trap gallery for hub members to share examples of error traps they have come across and also examples of where action has been take and worked.
View our error trap gallery and share your examples
1. Steve Highley. An Encounter with an Error Trap. 6 August 2015. https://www.hastam.co.uk/an-encounter-with-an-error-trap/
Advice for healthcare professionals
do not use glucose-containing solutions as infusates for maintaining arterial line patency, unless there are no suitable alternatives
saline infusions are recommended as the flush solution for arterial lines, to minimise the risk of incorrect blood glucose estimation and inappropriate insulin administration
if samples are drawn from arterial lines for estimation of biochemistry, a minimum volume of three times the dead space of the cannula system should be discarded first to avoid contamination[^4]
remain vigilant when selecting a solution for arterial line infusate. Similarities between glucose and saline solution bags means that confusion may occur
ensure that the arterial infusion line length is kept to the minimum necessary.
Coping with complexity: how a human factors systems approach can support competency development for pharmacists.
Support in clinical decision making is recognised as an educational development need for pharmacists. The health policy landscape puts the pharmacist in a central role for clinical management of long-term complex morbidities, making clinical decision making and taking responsibility for patient outcomes increasingly important.
This is compounded by the COVID-19 pandemic, where healthcare environments have become more complex and challenging to navigate. In this environment, foundation pharmacists were unable to sit the GPhC registration assessment during the summer of 2020 but provisionally the registration assessment is due to take place online during the first quarter of 2021.
In response to this, a suite of resources has been developed with collaboration between Chartered Institute of Ergonomics and Human Factors (CIEHF) and Health Education England (HEE). These resources are aimed in particular at early career pharmacists and their supervisors, especially those in foundation pharmacist positions managing the transition from education to the workplace environment.
This session will act as the launch event for these resources and can support early career pharmacists and supervisors to navigate the CIEHF learning resources developed so far.
The presentation covered:
What is Human Factors and ergonomics (HFE) and what it’s not
The basic principles
Why things go wrong (and right)
What’s happening in Scotland?
Practical human factors thinking
How to get involved
The goals of this Just Culture Manifesto are to:
articulate a vision of just culture that connects with people from all industrial sectors, around the world;
speak to people in all roles – front line, support, specialists, management, both in private industry, government organisations and departments, and the justice system;
provide a framework for other people to advance this vision of just culture.
As referred to in the Just Culture definition, only a very small proportion of human actions is criminally relevant (criminal behaviour, such as substance abuse or misuse, grossly negligent behaviour, intention to do harm, sabotage, etc.). Mostly, people go to work to do a good job; nobody goes to work to be involved in an incident or accident.
This 5 minute video, from MedStar Health, focuses on the human cost to our healthcare workforce when we fail to cultivate a just culture and systems approach overall, but especially when managing unfortunate harm events. This story has inspired conversation and can be used widely as a teaching tool.
When patient harm occurs, caregivers involved are often devastated along with the patient and family, yet many have had to navigate this storm alone. A systems approach in our healthcare workplace, along with the just culture, cultivates the sharing of knowledge and helps prevent patient harm from occurring altogether.
If you'd like to share your thoughts on Annie's Story, the systems approach and building a just culture, please comment below or join the conversation in our forum – Analysing events without blame or shame.
Whether you’re an industry or business leader, a human factors practitioner, researcher or academic, the Chartered Institute of Ergonomics & Human Factors showcase the very best that the discipline has to offer at one of the largest gatherings of ergonomists and human factors professionals in the world.
Further information and registration
WHO's definition of an After Action Review and resources
Guidance for After Action Review
After Action Review infographic
3 minute video explaining the AAR practice as promoted by WHO, including the definition, the different methodologies and available resources.
After Action Reviews and simulation exercises
Aimed 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 email@example.com
hub members can receive a 20% discount. Email firstname.lastname@example.org to receive the discount code.
Follow the conference on Twitter #HumanFactors
Mersey Care outlines the work they are doing to embrace a just and learning culture, centred on the desire to create an environment where staff feel supported and empowered to learn when things do not go as expected, rather than feeling blamed.
You can watch a short film about the issues they want to address and see how they've created a practical tool to aid some of the most delicate staffing conversations. They've also developed free online training aimed at HR staff but accessible to all from their web page.
Over the past three years, HEE has worked with its clinical leads, providers and more to address the report’s 12 recommendations:
Ensure learning from patient safety data and good practice.
Develop and use a common language to describe all elements of quality improvement science and human factors with respect to patient safety.
Ensure robust evaluation of education and training for patient safety .
Engage patients, family members, carers and the public in the design and delivery of education and training for patient safety.
Supporting the duty of candour is vital and there must be high quality educational training packages available.
The learning environment must support all learners and staff to raise and respond to concerns about patient safety.
The content of mandatory training for patient safety needs to be coherent across the NHS.
All NHS leaders need patient safety training so they can have the knowledge and tools to drive change and improvement.
Education and training must support the delivery of more integrated ‘joined-up’ care.
Ensure increased opportunities for inter-professional learning .
Principles of human factors and professionalism must be embedded across education and training
Ensure staff have the skills to identify and manage potential risks.
This has led to the implementation of many education, training and development schemes that promote safe clinical practice across all health and care services. This guide highlights many of the key areas where progress has been made, while offering a roadmap to what still needs to be achieved. Most importantly, it illustrates how all NHS stakeholders – including you – can get involved to help adopt and promote a safety-first culture whichever care sector you work within.