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In the 'Why Investigate' series we have considered the why, the who, the when, and the what, all related to the incident investigation process. We have looked at some of the technical aspects of Human Factors, and you have been upgraded to better writers than me – and some only wearing their underpants ('we have a situation blog'). Big congratulations to Lara ('ethics in research' blog) for submitting her PhD thesis and Alex ('making wrong decisions blog') now president of the Chartered Institute of Ergonomics and Human Factors. A welcome to the new MSc study types who will be contributing to the series: Afiah (rail) and Livia (marine). Normally by now we get into the interesting stuff about how to interview witnesses, limits of memory, general aspects of perception and action. However, this is healthcare – where I’ve said not many human factors types have ventured (sorry). This void or ‘vacuum of science’ appears to have been filled by ‘others’ who have what appears to be rather strange ideas, methods of investigation and data collection concepts. Philosophers (and writers that Alex’s blog highlighted) have noted that where a vacuum of science exists mankind returns to superstition and the like. Human Factors is often referred to by mainstream psychology people as ‘psychology in the damp, the cold and the wet’, or in my areas ‘psychology with the chance of getting shot’. In essence Human Factors is a postgraduate qualification where the willing participant spends a long time learning the science and the practices of the industries where they will work. Data from humans is difficult to obtain, time consuming and often only near the end of the study do you find that you asked the wrong question. Human Factors and psychology students spend a good portion of their course learning about statistics and research methods. Statistics is the greater part of this endeavour because when you collect data the natural variation within humans is often so vast you need statistics to understand how anything you did to the environment, the human, the equipment or method of working may have contributed to what you observed and the data you collected. I always recall the gasp of horror psychology undergraduates would make on their first research methods lecture as I wrote Greek letters on the board and talked about statistical variance. “I’ve come here to find myself, not to study symbols – I’m here to find out why I don’t sleep well”. If something is difficult, or is cold and involves wearing scrubs, body armour, or you go home smelling of diesel or jet fuel, its only to be expected some will think of avoiding those nasty things. Quick fixes typically involve a training course, and often watching peoples’ behaviours and then saying there are markers that mean something. Go on a course and you get a certificate to show you attended. Congratulations! You can detect the innermost workings of someone’s mind by observing them for a short amount of time. Yes, its psychobabble and it takes a while for science people – once they have showered and put their scrubs into the correct bin – to say hold on that’s wrong and dangerous. These next blogs will enable you to detect psychobabble and give you, dear reader (remember Mrs Trellis of North Wales from the questions and answers blog?), some questions to ask before you engage with this questionable endeavour, Let’s start with NTS, or non-technical skills. This is sometimes called the dirty dozen, or sometimes behavioural training. NTS originates in the aircraft maintenance world. The question is if two engineers operating on an aircraft is similar to a team operating on a person in theatre? Here I’ll cover a bit of history, some sources of reference that you can use and set the scene, get you thinking about collecting data and introduce the idea of measurement. Avid readers may recall I left you with an idea of some images that had clever maths associated with them (Why investigate, part 8). The three ideas I’m going to advance therefore are: Is there any face validity in the idea, and possible questions? What precisely do you measure, what is the scale and the units of measurement? What published science is there for testing it ‘beyond reasonable doubt’? Face validity and a simple test I was invited to a nice lunch, the sort of place without laminated menus. I was there after many years as a government science auditor to help other bits of government. The sales team pitching to government said that with training you can detect liars by observing if they looked up or down, and with extra training – purple belt associate grand wizard – you could get perfect memory, and with the green and purple belt and full wizard pass you could get other people to recall 100% of the memory with 100% accuracy. Impressive I thought, as I only recalled at the last moment that I was supposed to be there. Anyone who says 100% about humans – walk away. Just after arrival and seated with the ‘wizards’ I made an excuse to visit the toilets and went to the maître d and said – I’m from this bit of government and can you help run an experiment. I asked our waiter to remove his tie. At the end of the meal, hearing from them how human memory really works (and how traditional science gets it wrong), and how with their training you can see behavioural markers and this means you have 100% recall, I said: “That’s very impressive can you all do that 100% stuff?” They confirmed they could, so I asked: “What colour is the tie of our waiter”. Black was the answer, and I said, “is it a bow tie or a cravat?” All said they were 100% sure black bow tie. I beckoned our waiter over who held a tray over his front. Are you sure I asked? “Yes” they said. The waiter then removed the tray and showed he was not wearing a tie, and he confirmed that from the moment he came to the table he never wore a tie, unlike every other waiter in the place. So the moral is test any claims simply. It’s not science but it’s a starting place. Measurement Medicine is all about measurement, but when it comes to forensics in healthcare that’s often forgotten. I did a conference a few weeks ago and asked a colleague to name 12 different types of measurement. Micrograms, milligrams, pressure, beats per minute, centigrade, all sorts, were mentioned. NTS fans often reflect that a ‘lack of assertiveness’ is a causal factor of incidents. I’m going to use this example to demonstrate why measurement is essential in forensic investigation, proper conclusions and implementable recommendations. So, the question is, “what is the scale”, and if there is a lack of it, there must be the correct amount, and by implication too much. Perhaps it’s like the three bears and the porridge. Well not really, as porridge temperature can be measured in Fahrenheit or Celsius (editor points out in K). So what could the assertiveness scale be? Can you measure assertiveness or anything that’s a bit unusual? Well, if you visit those blurred images in my last blog I can describe them on a scale to three decimal places, and cite the metric, about each one and how blurred they were compared to the original. If you can measure and calibrate blur, then the idea is that science is about measurement. If you can’t measure it – does it exist? You are now thinking were all those images of the drug trolley really blurred – or was it just a long shift! How do you measure things you can’t see? Well wind is on the Beaufort scale. 1–12 with a light breeze (3), violent storm (11) and hurricane (12) as the labels. This is the inspiration of the assertiveness scale – there is a lot of hot air around. Force 5 assured assertiveness, gale 9 disapproval and violent storm stroppiness 11. NTS in this context makes little sense – think firstly about measure and scale. More in the other blogs. If you hear it – ask the proponent – what scale? I’ve chosen assertiveness as a medic was sacked for not having enough of it. They were not assertive to the surgeon, as the surgeon made the mistake. Well, how do you know they were looking at the surgeon at the time? And from our questions – was not the use of non-standard equipment, the 13-hour shift, and trainee scrub nurse asking questions more relevant? Simply, the incident will occur again. Sadly it did, 8 months later. Remember you investigate to stop the incident reoccurring; If you don’t get to the proximate cause, then it occurs again. What appears in court – investigations allowing 'beyond reasonable doubt' decisions I said that the idea of observing behaviour gets into forensics every now and then, but it’s dangerous in terms of why we do the investigation. It’s prevention – nothing else matters. We also do investigations for the court. Although these blogs look only at prevention, as there is a Duty of Candour, it might be worth a chat about investigations and metrics for court. Psychology used to be – in the 1940s – all about behaviour, but we have moved on. During the 1990s and early noughties it was the idea that you can work out intentionality, drug abuse, alcohol consumption, just by watching how someone walked. Forensic gait analysis it was called. Essentially, any aspect of human behaviour can be assessed by seeing someone walk. A case I dealt with was blessed by people who said, from viewing degraded video images (a frame every 2 seconds), that you can tell that a driver was fit but not happy by the way they walked. You can make this assumption by never seeing any comparative degraded video of the same person or any other data sources. Forensic gait analysis was starting to get into court. Rightly the lovely judiciary questioned the science. The Royal Society and the UK top judges started a series of guides as to science in court. Remember, in court the measure is ‘beyond reasonable doubt’. The Royal Society and the judges asked for a panel of writers to comment upon science. The writers are typically world leaders and their work is reviewed by many top science types. Gradually the ‘primers’ are being published. Useful source of forensics here for investigators. Gait analysis report – well you have predicted the findings, and judges are now cognisant of the facts and the danger of watching behaviours as evidence to be used in court. Of course, it’s still up to the judge to decide what happens in their court and personally I defend that right absolutely. On the Royal Society Science and the law page, it shows that statistics, etc., are also subject to guidance. The latest one is about incident investigation in transport and Human Factors and sets the scene about Human Factors very well. It’s a good starting place for understanding Human Factors. Summary There is a lot of non-science out there. Data are collected in ways that make science types shudder. Behavioural markers are not robust and reliable on their own. Humans do not have the skill to generate good data and prevent incidents re-occurring just by watching each other. Remember we investigate to stop the incident occurring again. To get my classic literature quote in to conclude: "The life of the dead is placed in the memory of the living." [Marcus Tullius Cicero, 106 – 43 BC] Finally To answer a number of questions about my last blog saying there is a regulator in this domain and comments received saying I don’t know what I’m talking about because it’s all done by institutes and there definitely is no government regulator, absolutely not and no way there is a regulator. Here is the government regulator website: www.gov.uk/government/organisations/forensic-science-regulator. This maybe useful for those thinking about investigation methods. Alex has covered the main papers from the regulator on biases on reasoning (making wrong decisions blog) and I’ll do the issues of statistical fallacy. Those in Scotland who have read ahead – yep correct, it’s also known as the prosecutor's fallacy, and yet another issue with root cause analysis. Post script... We are very aware that we are pointing out lots of problems without offering any solutions. Shortly Alex, Graham and myself will be offering some courses. We have avoided virtual learning as all three of us have thought about its problems. However, we believe that if we teach Human Factors and forensics in the three domains – the environment, the equipment, and the human – then we need to have those things present and to hand. We wish to avoid the phrase, ”Imagine there’s defib machine, imagine there is a ward, imagine the person is fatigued…". Read the other blogs in this series 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. How or Why. Part 6 Why investigate? Part 7 – The questions and answers Why investigate? Part 8 – Why an ‘It’s an error trap conclusion’ is an error trap Why investigate? Part 9 – Making wrong decisions when we think they are the right decisions Why investigate? Part 10. Fatigue – Enter the Sandman Why investigate? Part 11: We have a situation Why investigate? Part 12: Ethics in research

Six months ago, I left my band 7 managerial role to work as a band 5 agency nurse on the wards. Despite the band drop, this move has financial advantages which will help me to achieve some personal goals. Signing up After successfully completing the recruitment process, I am asked to attend mandatory training. This includes basic life support, manual handling and infection control. The usual, run of the mill stuff. I can book shifts a week or a day in advance, but these shifts can change to any speciality or department in the hospital, depending on staffing levels. I book my first shift after six years of having not worked within a ward setting. An unsafe start I turn up to the shift and introduce myself to be met with a mutter. The team and I receive handover and I am allocated my bay of patients. I notice I have twelve patients, three more than the other nurses. I reiterate this is my first time here and that I haven’t worked in ward work for some years. I ask if it would it be possible for someone to show me around – resuscitations trolley, toilets, codes to the drug cupboards. General housekeeping. I receive a grunt and a point, followed by some numbers hurled at me, along with keys. Ok, perhaps they’re just not morning people. I will give them the benefit of the doubt. Off I go to introduce myself to my patients and to immediately make use of my prioritisation skills, escalating any concerns I have to the seemingly disengaged shift leader and (more helpful) doctors. I find that my patients are acutely unwell and in need of a lot of care. I have to remind myself of my 13 years’ experience and how good I am at communicating, reassuring myself I will be ok. Hours later and still no toilet break Seven hours later, hungry and in need of a wee, I ask my shift leader if she could cover me so I can take a break. I am met with, ”your patients are too unwell for you to leave them for 15 minutes, and I don’t have the staff to cover you”. Followed by the ultimate toxic saying within the NHS, ”that’s just how we do it here, always have”. I start to feel neglectful that I would even have thought to have a drink and pass urine. Ten hours pass and still I haven’t had any water or a wee. Three emergencies have taken place without me even having had a proper induction. I take solace in my bond with my patients and lovely doctors who understand how it feels to be isolated and new to an area. Speaking up Perhaps out of dehydration and kidney shut down, I find the voice to politely approach the other nurses and shift leader. I explain that my patients are now stable and highlight my own personal fluid needs. I mention that I still haven’t received an induction. No one has asked me my skills or background nor if I know how to use the different IT systems (drug charts are now on computers). Again, I am met with, “well you choose to be agency, we just all get on with it here”. These are words that frighten me. It isn’t safe to get on with it. I felt out of my depth, overwhelmed, deprived of basic human rights and unwell. Losing confidence Then, a patient’s relative approaches me to say, ”I didn’t want to trouble you as you were running around looking so busy, but dad has chest pain”. At that point my heart breaks. How have I given the impression that I am the unapproachable one on this ward? Have I neglected this poor man? The same man who had cried with laughter at a joke I had made about some TV show we both watched the night before while I was catheterising him. Protocol follows and I investigate his chest pain. No acute cause. Phew. I still leave his side feeling that I am terrible at this. The end of my shift approaches, still no break, still no water or food. Handover time… I introduce myself to the night team. Finally, someone kind welcomes me to the ward. They tell me they all feel like they are doing a bad job and not giving satisfactory care. I think they are trying to reassure me. I cycle home in tears; shattered and broken. The next day I have serious doubts about my own ability. I call my agency and have a long chat with my recruitment consultant (who has never set foot inside a hospital and works on commission). His response? ”Well, you don’t have to go back”. I start to have serious doubts about my choice to work in this way and feel even more perplexed that our wards and teams have become like this. What a difference a day makes My next shift is in an emergency department. Dreading it, I don’t sleep the night before and I turn up riddled with anxiety about what is to fall upon me. I meet the team and prep myself to ‘kill them with kindness’. Everyone is pleasant and welcoming. The senior nurse asks me about my skills and mandatory training and shows me around. She informs me of their expectations and what I could, in return, expect of her team. It seems so simple, a five-minute job, huddling with your team for the sake of patient safety. But what a huge impact it has on my shift. My patients are more acute, I am busier and still don’t urinate. But I am supported and able to escalate concerns without being gas-lighted. Final thoughts I have now booked all of my shifts on that busy emergency department, simply because of the manager. I respect her management style and her approach to the safety of her unit. She doesn’t use those unhelpful and unsafe words, ”we just get on with it” or ”that’s how we do it here”. Since becoming a bit more settled in this world of agency nursing, I have spoken with matrons and lead directorate nurses within this trust about my experience. Often met with, ”what can I do about that?”. But sometimes met with, ”I will look into how that particular ward manages staff safety”. The latter leads on to better patient safety. Key learning points Inductions to new staff in new areas, should be mandatory. It should be the nurse in charge's duty to support junior staff. Doing safety rounds and checking in on all staff would help to manage workload, support flow and build confidence and reassurance among staff on duty. Safety huddles at the beginning, middle and sometimes end of each shift are a simple way of combating so many of the patient safety issues raised in this account. Early warning scores should be displayed and visible for all professionals on duty. They should be checked regularly and actioned accordingly.

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.

In this short blog Steven Shorrock gives us some tips on how to 'do safety II'.

The website includes links to: Information on the #FakeMeds campaign Register of authorised online sellers of medicine How to use self-test kits safely Yellow Card to report any suspected fake medicines or side effects Information about the CE Mark

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?

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 variability and are constantly preoccupied with the possibility of failure.

This guidance for medical doctors explains how to apply the principles of good medical practice. It is separated into two parts: Part 1: Raising a concern - gives advice on raising a concern that patients might be at risk of serious harm, and on the help and support available to you. Part 2: Acting on a concern - explains your responsibilities when colleagues or others raise concerns with you and how those concerns should be handled.

The Global Drug Policy Index measures how drug policies align with many of the key UN recommendations on how to design and implement drug policies in accordance with the United Nations principles of health, human rights, and development. The Index is composed of 75 indicators that run across five dimensions: The absence of extreme sentencing and responses to drugs, such as the death penalty The proportionality of criminal justice responses to drugs Funding, availability, and coverage of harm reduction interventions Availability of international controlled substances for pain relief Development The UK scores relatively low on 'Proportionality and Criminal Justice' and there is a need to reflect on this at a policy level. Read testimonies of people who have been directly affected by drug policies in the 30 countries covered by the Global Drug Policy Index.

"Several concerns have been raised about the risk of overdose and death from oral morphine sulphate solution over the past few years, but they have gone unheard." In light of coroners reports of deaths related to abuse, or accidental overuse of Oramorph or oral morphine sulphate solution. the author argues for increased regulation. Commenting: "In the absence of any action from ministers, it seems that healthcare professionals are going to have to take the care of vulnerable patients into their own hands." My reflections on this are: Is this a signal for increased regulation or improved prescribing practice, improved medicine management, and more education & acces to trusted information for patients? Would there be downsides to increased regulation?

Key points Smoking, poor diet, physical inactivity and harmful alcohol use are leading risk factors driving the UK’s high burden of preventable ill health and premature mortality. All are socioeconomically patterned and contribute significantly to widening health inequalities. This report summarises recent trends for each of these risk factors and reviews national-level policies for England introduced or proposed by the UK government in England between 2016 and 2021 to address them. Based on our review, it assesses the government’s recent policy position and point towards policy priorities for the future. Population-level interventions that impact everyone and rely on non-conscious processes are most likely to be both effective and equitable in tackling major risk factors for ill health. Yet recent government policies implemented in England have largely focused on providing information and services designed to change individual behaviour. As well as relying heavily on policies that promote individual behaviour change, the strength of the government’s approach has been uneven for the leading risk factors, and decision making across departments has been disjointed. Action to tackle harmful alcohol use in England has been particularly weak. To reduce exposure to risk factors and tackle inequalities, government will need to deploy multiple policy approaches that address the complex system of influences shaping people’s behaviour. Population-level interventions that are less reliant on individual agency and aim to alter the environments in which people live should form the backbone of strategies to address smoking, alcohol use, poor diet and physical inactivity. These interventions need to be implemented alongside individual-level policies supporting those most in need. The strong role played by corporations in shaping environments and influencing individual behaviour must also be recognised and addressed in a consistent way through government policy. The costs of government inaction on the leading risk factors driving ill health are clear. As the country recovers from the COVID-19 pandemic and seeks to build greater resilience against future shocks, now is the time to act.