Human factors in healthcare : level two

239 Pages·2015·1.354 MB·English

by  Debbie Rosenorn-Lanng

Human Factors
in Healthcare

Human Factors
in Healthcare:
Level One
DEBBIE
ROSENORN-LANNG
1
1
Great Clarendon Street, Oxford, OX2 6DP,
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First Edition published in 2014
Impression: 1
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In memory of Carol and my dad;
in the hope that we will learn from our mistakes.
Acknowledgements
I would like to thank my future husband, Steve, for his endless patience, under-
standing, and encouragement. Between us we have six wonderful children who
make me laugh and lift my spirits on difficult days—thank you.
I would not have finished the book without the support of my mum, also the
ideal role model for resilience, who has always been there for me—thank you.
Niki, you will be an inspirational cancer survivor. I hope that by the time I finish
my second book, your blog will be ready and I will be able to point people in
your direction. Your courage and strength of spirit have been truly heroic. Fol-
lowing your story made me realize that writing a book may have its challenges,
but they were always so small relative to the ones that you were facing.
I would never achieve anything without the support of my metaphorical right
hand, thank you Sue. I would like to thank Vaughan Michell for the help, energy,
and intellectual stimulation that you have provided. I would also like to thank
Lizzie, Vaughan, Prad and Sue for their help with the SHEEP sheet.
To John Gattrel and Chris Gale, I thank you for your mentorship and for your
roles in my personal development. To Professor Kercheng Liu and Jonathan
Fielden, thank you for believing in me. Thank you to Mel and Luke with whom
I have loved working and who demonstrate dogged determination and calmness
under pressure. The list of wonderful staff with whom I have worked is endless
but a few have truly inspired me as I progressed through my career: Dr Carol
Barton, Dr Tim Parke, Dr Rachel Hall, Dr Pat Brock, and Dr Ramesh Naik
are amongst those. I would like to thank Julia Harris and John Reynard for
the inspirational support they provide as fellow executive leads for the Patient
Safety Federation Human Factors workstream.
I would like to thank Nicola and Caroline at Oxford University Press: the for-
mer for backing me and the latter for her patience and support as I progressed
somewhat sedately up the publishing learning curve.
I would like to thank Martin Bromiley and Clare Bowen for the bravery they
have shown in sharing their stories so that we might learn.
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Contents
Introduction viii
1 Human factors: so what’s it got to do with me? 1
2 The ‘S’ of SHEEP: Systems 21
3 The ‘H’ of SHEEP: Human interaction 45
4 The ‘E’ of SHEEP: Environment 92
5 The second ‘E’ of SHEEP: Equipment 112
6 The ‘P’ of SHEEP: Personal 140
7 Communication: face to face is best 173
8 Error awareness 194
Appendix 1 211
Appendix 2 215
Index 217
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Introduction
Be the change you want to see in the world
Mahatma Gandhi
(paraphrased from The Collected Works of M.K. Gandhi, Volume 13, Chapter 153,
p. 241, The Publications Division, New Delhi, India, 1913)
But why do we need to change?
Frightening fact: across the NHS we currently harm around 1 in 10 patients.
Most complaints from patients and relatives are due to human factors. The
Medical Protection Society states that 80% of litigation is due to human fac-
tors. Most people on the frontline in healthcare have little or no idea of the
meaning of the term ‘human factors’.
The time has come to fill in the gaps. The time has come to promote safety-
positive behavioural culture change.
There is now a realization that knowledge and competence are not enough,
and without what are now termed ‘non-technical skills’, fatal errors can and
do occur. I like to think of human factors as the metaphorical glue that sur-
rounds knowledge and skills. It is also the link between the individual and the
systems which govern how they work, the environment they find themselves in,
the equipment with which they work, and the team or teams that they interact
with, as well as interacting with the patient.
These ‘soft skills’ are perhaps perceived as not as exciting as wielding a scalpel
and yet it is these same soft skills which are what holds a life-saving emergency
procedure together.
The communication, the leadership and team working, the task management,
the decision-making, the situational and risk awareness, the error management,
and the systems approach to safety are essential skills worthy of a place in medi-
cal education.
As history unfolds, it seems often to be the case that it is only following a crisis
that we gather sufficient inertia to set about initiating change. I hope that the
Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis Report) will
Introduction
be one such turning point in healthcare. I wish to help initiate the new ideal of
a ‘learning culture with continuous improvement’.
I hope by the end of the book you will want to join with me to produce this
overdue change.
Limited pockets of enthusiasm
It is true to say that there are areas who have grasped the nettle firmly. For
example, the anaesthetists and surgeons have developed ANTS and NOTSS
(anaesthetic non-technical skills and non-technical for surgeons) and there is
now a chapter in the ALS manual devoted to human factors. However, research
indicates that the majority of healthcare workers have little or no understanding
of the term or the skills, attitudes, and behaviours that underpin this discipline.
What to expect in the chapters ahead
A new model for human factors by healthcare professionals for healthcare pro-
fessionals has been developed. The approach takes you through a step-by-step
process to become more self-aware of your own human factors and how to
improve them.
Human interaction, task management, team working, ergonomics, environ-
mental and equipment design, and designing systems with safety in mind are
explored in depth.
The topic of error is covered in a way that encourages the focus to be on suc-
cessful error management rather than blame with a ‘big stick’ idealism. The
method promotes a move towards a risk-aware culture where people are open
and willing to learn from their mistakes.
Examples of poor behaviour are unfortunately far too common within the NHS
environment. This behaviour has gone unchallenged for years and in some plac-
es has been accepted as the norm. The time has come to equip people with a
new skill set that encourages this behaviour to be challenged (see Example 1).
Example 1 Examples of poor behaviour
As a junior doctor, I witnessed equipment being launched across an operat-
ing theatre in a sea of rage, regular humiliation of junior doctors and nurs-
ing staff, angry outbursts reducing staff to tears, patients being ignored, and
people being just plain rude. I saw this behaviour go unchallenged, ‘Oh, so
and so, is always like that, it’s just their way’.
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