"Subclassing and Composition – A Pythonic Tour of Trade-Offs", Hynek Schlawack
Parallel Session 3.5 Crossing Boundaries to Improve Outcomes
1. HUMAN FACTORS
Dr Rona Patey
Consultant Anaesthetist NHS Grampian
Head of Division of Medical and Dental Education
University of Aberdeen
2. Who are we?
1. Nursing
11%
2. AHP
11%
3. Medicine
11%
4. Healthcare education – undergraduate
11%
5. Healthcare education – postgraduate
11%
6. Healthcare management
11%
7. Human factors research
11% 0
8. Human resources of
11% 100
9. Other
11%
3. Are you currently working on a human
factors initiative?
20%
• Yes – still in planning stage
20%
• Yes – within my team
20%
• Yes – across institutions
0
20% of
100
• No – but I would like to
20%
• No
4. Have you had previous education / training
around human factors?
20%
• No, not really thought about it
20%
• No, but would be keen to know more
20%
• Yes, a one off session
20%
0
• Yes, as part of a larger programme of
100
20%
• Don’t know
6. Human Factors
• ‘the scientific discipline concerned with the understanding
of interactions between humans and other elements of
the system, and the profession that applies theory,
principles, data, and methods to design in order to
optimise human well being and overall system
performance’
International Ergonomics Association 2000
7. Human Factors
• Organisational / • Workgroup(s) / Team (s)
management – Team structures / processes
– Safety culture – Team leadership
– Management • Individual worker
leadership – Cognitive
– Communication • Situation awareness
• Work environment • Decision making
– Work environment and – Personal resources
hazards (ergonomics • Management of stress
• Management of fatigue
8. Exercise
• A picture will appear on the screen for around 15
seconds
• Examine the picture closely and look for a change
• Raise your hand when you spot a change
9. Safety
• Error is inevitable and ubiquitous!
– Humans are fallible
Helmreich 1996
• Critical incident students reveal that around 80% of
underlying issues relate to human factors
– Frequently avoidable
10. Wrist
Admitted On 5
fracture six
with UTI Medications
months ago
Mobilises with
a frame Lack of
staff training
Accident
Trajectory
Patient Drug Chart
Condition Medical Records Ward
Workforce &
Environment
Communication
The latent failure model of complex system failure
modified from James Reason, 1997
11. Safety
• Systems should be designed with ‘defenses in depth’
– Organisational, management, equipment design,
workspace layout
– Should provide the human in the systems with the
necessary knowledge and skills to deal with threats in
their environment / to act as hero
• technical skills are not enough!
Reason 1997
12. Lessons from other industries
• Human factors & safety integrated to the core curriculum
– undergraduate
– continuing professional development
• Compulsory adverse event reporting with investigation
and learning (organisation and industry)
• Briefing and debriefing part of the culture
13. Lessons from other industries
15/1/2009
Flight 1549
Routine flight from New
York to Charlottesville
17. ANTS System
Categories Elements + Confirms roles and responsibilities of
team members
+ Discusses case with surgeons or
Task Planning and preparing
colleagues
Management Prioritising + Considers requirements of others
Providing and maintaining standards before acting
+ Co-operates with others to achieve
Identifying and utilising resources
goals
Team Co-ordinating activities with team members Example behaviours for
Working Exchanging information good practice
Using authority and assertiveness
Assessing capabilities
Supporting others Example behaviours for
poor practice
Situation Gathering information − Reduces level of monitoring because
Awareness Recognising and understanding
of distractions
Anticipating − Responds to individual cues without
Decision Identifying options confirmation
− Does not alter physical layout of
Making Balancing risks and selecting options
Re-evaluating workspace to improve data visibility
− Does not ask questions to orient self to
situation during hand-over
20. Human Factors
http://www.chfg.org/
‘about making it easier to do the right job’
Martin Bromiley
21. Human factors training should be
incorporated as a core skill?
20%
• Strongly Agree
20%
• Agree
20%
• Neutral
20% 0
of
• Disagree 100
20%
• Strongly Disagree
Notes de l'éditeur
overview
We know that things do not always go right! Major disasters – but following common mistakes and practises RF investigation of piper alpha
Human Factors scientists / discipline
What might these scientists consider – RF detail
Why do we need people to understand humans, their behaviour and how they interact with workplace? Exercise to indicate our own fallibility and the ubiquitous nature of this
Error major issue in all domains we are aware of
Clinical example – contrasting individual blame versus system attention, investigation and adaptation
Reason
What do other industries do that is different from healthcare? Are there examples we can learn from
Airline – humans as hero Work in simulation Not just about the scientists but also about the practitioners taking a human factors approach to their daily work
What about healthcare – highly complex challenging workplace
Calls for inclusion of human factors to be integrated to healthcare education and the way that we work and think Link to simulation
RF Work at on identification and development of NTS taxonomies for some h/c practitioners – GGY work with surgeons & link to simulation
What do these things look like and how might use them – link to simulation
What else is happening in healthcare – back to surgery – link to GGY RCS and also SPSP
An example where HF approach can make a difference to practice of individuals, reliability of system
Back to what is human factors about – martin bromiley quote