On 6th March, we were pleased to welcome Dr Rob Galloway, ED Consultant from Brighton and Sussex University Hospital, to deliver a one day Human Factors training event at ASPH.
Human Factors was defined by Catchpole, of the Clinical Human Factors Group in 2010 as; “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities, and the application of that knowledge in clinical settings.”
As Rob explained to us last month, this is a very wordy and difficult to understand definition, which seems to go against his philosophy of “reducing errors by safe clear, unambiguous English”.
So, put simply, Human Factors is “how to behave and think at work”.
Rob spoke at the event about the need for a change in culture in order to reduce adverse events occurring in our hospitals; we all need to feel able to speak out when we see errors or poor leadership. We also need to get better at learning from mistakes and errors, using reflection to learn and identify areas for improvement.
Rob shared many examples of serious and simple mistakes, some that had led to patient harm. It was apparent from these examples that the errors and mistakes that occurred were not deliberate acts of malice, but simple human error that any one of us could have carried out; drug containers that look identical, poor communication, miss-read blood results, poor understanding of risk information, becoming focussed on the wrong clinical signs.
We discussed how it is essential that we modify our behaviours and value our teams if these sorts of harms are to be reduced in our healthcare system. Only by accepting and recognising that we are all human, will things improve.
Communication is a big theme and Rob described some helpful tools to help; SBAR for clinical handover and PROBE for escalating concerns (more detail on these can be found on clinicalsafety.org)
Having recently read an interesting article form BMJ Quality and Safety which discusses the benefits of integrating Human Factors (HF) and Quality Improvement (QI) for safety in healthcare, we thought this was worth sharing too.
I think that, here at ASPH, we are already integrating these two approaches, but it was interesting to read how they both can be applied differently to a problem; QI to ensure a good understanding of the problem, measure the current state and formulate plans for testing a change; Human Factors to understand the human requirements for the change – looking at how people behave within the system, how decisions are made and the human interactions that occur and then designing the change with the people involved.
I do think that we already consider both the process and human elements of a change here at ASPH, but it is a useful reminder to make sure we always consider the human elements of any change.
We recommend that you take time to read more about Human Factors and the campaign to improve safety through the use of clear, unambiguous language here – https://www.clinicalsafety.org/
You can also read more about Human Factors and quality improvement here – http://qualitysafety.bmj.com/content/qhc/early/2015/02/25/bmjqs-2014-003623.full.pdf
We work in a complex system and using these two approaches will enable us to understand both the systems and processes that we are aiming to improve and the way in which people perform within them. Our learning from Rob and others is that, without both, we cannot hope to make a successful and sustainable improvement.
Sally – @Sally2PT