Patient Safety

Patient story

“A patient was scheduled for a right knee arthroscopy, seen by the consultant and the consent form filled in correctly.  The right leg was marked but the procedure was initiated? on the left knee until the theatre assistant noticed and spoke up. The procedure was stopped and the right knee investigated as required.

The following failings were later identified:

1. The person operating was not the same as the person taking consent and marking the site.

2. The site marking was not prominent or undertaken in accordance with policy.

3. The WHO Surgical Safety Checklist wasn’t used in this theatre and there was no time out or verbal check of the site for surgery or position of the table before the procedure started.

4. The scrub nurse rotated the table for the left knee which caused confusion and set everyone up to think it was the left knee to be operated on. The nurse then left theatre and didn’t return until the procedure was underway.” (National Quality Board, 2013: 11)

Human Factors

'Human Factors' is a discipline that seeks to optimize the relationship between technology and humans, applying information about human behaviour, abilities, limitations, and other characteristics to the design of tools, machines, systems, tasks, jobs and environments for effective, productive, safe and comfortable human use. Human factors issues are major contributors to adverse events in health care, and you can probably see how they played a significant part in the patient story above. 

It is possible to manage human factors by application of proactive techniques aimed at minimizing and learning from errors or near misses. Aviation is a good example of an industry which has embraced the study of human factors as an approach to improving safety thereby resulting in phenomenal decrease in aviation disasters. The human brain is very powerful, very flexible, good at finding shortcuts, good at filtering information, but prone to distractibility which helps humans notice when something unusual is happening consequently recognizing and responding to situations rapidly and adapting but this also predisposes humans to error.

Situations that increase the likelihood of error include unfamiliarity with the task (especially if combined with lack of supervision), inexperience, shortage of time, inadequate checking, poorly designed procedures and poor human-equipment interface. Individual factors that predispose to error include limited memory capacity which is further reduced by: fatigue, stress, hunger, illness, language or cultural factors, hazardous attitudes. Sleep deprivation of 24 hours has a performance effect equivalent to blood alcohol content of 0.1%. Ways to put knowledge of human factors into practice include: applying human factors thinking to work environment, avoiding reliance on memory, making things visible, reviewing and simplifying processes, standardizing common processes and procedures, routinely use checklists and decreasing reliance on vigilance (WHO, 2012)

Now please read the World Health Organization’s handout on “Why applying human factors is important for patient safety” here

Optional reading for this Topic include:

Patient Safety- The role of human factors and systems engineering (Carayon, 2010) and Patient Safety Primer- Human Factors Engineering (AHRQ. 2019)

References and Resources

Agency for Healthcare Research and Quality (AHRQ) (2019) Patient Safety Primer- Human Factors Engineering. Patient Safety Network (PSNet). [Online][Accessed on 1st October 2023][Available at https://psnet.ahrq.gov/primer/human-factors-engineering] 

Carayon, P., & Wood, K. E. (2010). Patient Safety: The Role of Human Factors and Systems Engineering. Studies in Health Technology and Informatics, 153, 23–46. [Online][Accessed on 1st October 2023][Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3057365/]

National Quality Board (2013) Human Factors in Healthcare. A concordat from the National Quality Board [Online][Accessed on 1st October 2023][Available at https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-hum-fact-concord.pdf]

World Health Organization (WHO) (2012). Why applying human factors is important for patient safety? [Online][Accessed on 1st October 2023][Available at https://cdn.who.int/media/docs/default-source/patient-safety/curriculum-guide/resources/ps-curr-handouts/course02_handout_why-applying-human-factors-is-important-for-patient-safety.pdf?sfvrsn=861a3034_9&download=true