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Human Factors

Jan Shaw

Manchester Royal Infirmary

CMFT
Human Factors
 Human factors theory focuses on a
range of topics associated with
human abilities, behaviours and
limitations in the context of
workplace safety

 Theory operates on 2 levels

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Human Factors & Systems

 The theory can be applied to

influence the design of systems,
tasks, equipment, workplace
layout, job planning etc to make
allowances for human capability in
complex working environments

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Human Factors & Individuals

• At an individual level, human

factors theory describes the non-
technical skills which complement
individual technical skills to
facilitate safe and efficient
performance of tasks

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Non-technical Skills
Cognitive, social and personal skills:

• Effective communication
• Team working
• Leadership
• Decision making
• Situation awareness
• Stress management
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Error Chains
System
Latent Human
Active Happen-
Catalyst
Failures
Errors Failures
Errors Events
stance

Unsafe
Situation

Poor Situation
Awareness

Final Error
(Point Of No Return)

ADVERSE EVENT
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Swiss Cheese Model
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Swiss Cheese Healthcare Model
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System design & management

Equipment

• Equipment shortages

• Inadequate maintenance of equipment

• Incompatible goals (e.g. conflict

between financial and clinical need)

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System design & management

Training
• Inexperienced personnel working
unsupervised

• No scheduled training sessions for

updating staff in the use of new
techniques / equipment

• Inadequate knowledge or experience /

incomplete training

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System design & management

Communication

• Inadequate systems of communication

• Loss of documentation (e.g. previous

patient records not available)

• Highly mobile working arrangements

leading to difficulties in communication

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System design & management

Situation Awareness
• Organisational & professional cultures which
induce or tolerate unsafe practices

• No requirement at organisational level to

undertake formalised checking procedures

• Heavy personal workloads / lack of time to

undertake thorough assessments

• Reluctance to undertake a formal analysis of

adverse events / learn from errors

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Theatre Team
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Working in Silos

Anaesthesia Surgery Nursing

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Working in Silos

Wards Theatres Intensive Care

Individual & Team Non-technical Skills
Communication & Teamworking
• Incomplete or inadequate briefing and handovers / poor
or non-existent debriefing

• Poor or dysfunctional communication - especially

between specialities

• Failure to follow advice from a senior colleague

• Failure to formulate back-up plans and discuss with the

team members

• Lack of clarity in team structures (e.g. in a

multidisciplinary team, who is in charge?)

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Individual & Team Non-technical Skills

Decision-making

• Failure to undertake appropriate

preoperative investigations

• Failure to use available equipment (e.g.

capnography)

• Attempts to use unfamiliar equipment in

an emergency situation

• Casual attitude to risk / overconfidence

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Individual & Team Non-technical Skills
Leadership & Task Management

• Peer tolerance of poor standards

• Failure to take and document a comprehensive

history / perform an airway assessment

• Failure to request previous patient records

• Inadequate checking procedures

• Failure to cope with stressful environment /

interruptive workplace

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Individual & Team Non-technical Skills

Situation Awareness

• Fixation errors, resulting in a failure to

recognise and abort a plan which is not
working, and move to another potential
solution

• Wrong interpretation of clinical findings

/ test results

• Frequent / last-minute changes of plan

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Panel Assessment

Poor judgement
- Contributory in 46%
- Causal in a further 10%
Good judgement
- Mitigated against a worse
outcome in 13%

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Panel Assessment

Team & Social behaviours

- Negative effect in 18%
- Positive effect in 10%
Communication behaviours
- Negative effect in 22%
- Positive effect in 21%

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Reporters’ Comments

 
Defective Judgement Poor Teamwork

56% (74/133) 14% (18/133)

Anaesthesia

17% (6/36) 5.5% (2/36)

Intensive Care

Emergency 47% (7/15) 20% (3/15)

Department

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Recommendations
Education

• Introduction of safety training into all anaesthetic,

intensive care and emergency department
curricula at the earliest possible stage

• Provision of HF training as part of corporate

mandatory training for all members of staff who
work with patients with difficult airways

• Opportunity for multidisciplinary teams working

with the difficult airway to train together within
simulated scenarios to practise technical and
non-technical skills

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Recommendations

Guidelines and protocols

• Guidelines and emergency algorithms

should be immediately available in all
clinical areas where airway
emergencies may arise

• Team training scenarios should

reinforce the use of guidelines within
the clinical arena
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Recommendations

Building an organisational safety culture

• Airway incidents, including near misses,
should be routinely reported and regularly
audited

• Investigations into adverse events should be

performed according to best practice to
determine if changes need to be made to
make the systems safer for future patients

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Recommendations

Improving communication
• Organisations should encourage the use of
routine briefing and debriefing - as
recommended by the NPSA. In particular this
should occur before management of an
anticipated difficult airway and after such
management or a critical airway incident

• Consultants and senior staff should lead by

example and use briefing and debriefing
techniques in these clinical situations

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