Human Factors & remote islands considerations

1. Human Factors & remote islands considerations Mark Johnston Training and Research Officer (Patient Safety) NHS Education for Scotland mark.johnston@nes.scot.nhs.uk 0131 656 3258 Culture Workspace @markjohnston71 Behaviours and Abilities Adapted from Catchpole

2. Pre-requisite and/or reflective learning • E-learning course (for details see handout) • Introduction to Patient Safety • Managing Human Error • Suggested reading and resources (for details see handout)

3. Learning Outcomes • At the end of the session you will be able to • Define Human Factors • Describe how factors impacting on an individual may increase the likelihood of error • Explain the systemic factors that increase the likelihood of error • During the session you will • Participate in discussion with delegates

4. How safe is healthcare? • What percentage of patients entering acute care will suffer an adverse event? • NES 2013 • The picture in primary care… • 11% of prescriptions may contain a mistake • 5% of hospital admissions are caused by medication issues • Bowie, P. 2010 10%

5. Why do all those avoidableharms happen? • Bad people? • Error occurs due to Systemic and Systemic induced Individual failure • Negligence is not the same as error, both may result in harm

6. HF facilitators workshop Sept 11 5 6

7. Why do we make mistakes? Sometimes we do the wrong thing, consciously and sub-consciously

11. Even experts make mistakes

12. Why do we make mistakes? The system may be set up to fail ‘every system is perfectly designed to achieve the results it gets’ Peter Senge.

14. Your amazing!

15. Why do we make mistakes? Sometimes we do the wrong thing, consciously and sub-consciously

16. Driving 100 mph illegal for all Borderline Tolerated Conditions of Use Driving 75 mph – the ‘illegal-illegal’ space (for almost all of us!) Individual Pressures Individual Autonomy Driving 64 mph -the illegal- normal space Perceived Vulnerability VERY UNSAFE SPACE The posted speed limit is 60 mph- the ‘legal’ space Accident Belief in Systems- guidelines <1% 5% 50% 80% 100% percent of drivers PERFORMANCE Adapted from Rene Amalberti

17. Human FactorsA common language “Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings” (Catchpole 2010) “Making it easy to do the right thing” (Bromiley 2011) • Individual Worker • -Cognitive skills • Situation awareness • Decision making • - Personal resources • Management of stress • Management of fatigue Organisational/ Management -Safety Culture -Managers’ Leadership -Organisation communication Work/Environment -Work environment and hazards (ergonomics) Workgroup/Team -Teamwork structures & processes -Team Leadership (Flin, Patey 2012)

18. The amazing colour changing card trick http://www.youtube.com/watch?annotation_id=annotation_262395&feature=iv&src_vid=voAntzB7EwE&v=v3iPrBrGSJM

19. The first lesson in reducing harm is the realisation that we will and do make mistakes ‘It’s the downside of having a brain!’ Reason

20. Scenario 1 • Read the summary of the GP incident • (Wrong address delays resuscitation) • Why do you think this near miss happened? • What would you do to minimise its occurrence in future?

21. Where can we start? “Making it easy to do the right thing” (Bromiley 2011) Work/Environment -Work environment and hazards (ergonomics) (Flin, Patey 2012)

22. ‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’ Reason J. BMJ. 2000 March 18; 320(7237): 768–770.

23. Everyone, everywhere, every time Good human factors design in health care accommodates everyone Not just the calm, rested experienced healthcare worker But also the inexperienced health-care worker who might be stressed, fatigued and rushing.

25. Where can we start? “Making it easy to do the right thing” (Bromiley 2011) Organisational/ Management -Safety Culture -Managers’ Leadership -Organisation communication (Flin, Patey 2012)

26. ‘We cannot change the condition of those who do the work, but we can change the culture within which they work’

27. What is your culture? Nurses Admin Doctors Silo working?

28. Hierarchies?

29. Do we pay attention to the Swiss cheese or do we blame? Our learned behaviour is to blame an individual Society System End point (HCS Colleagues)?

30. Lessons for Leadership inchanging culture Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours. Berwick Report 2013

31. Where can we start? “Making it easy to do the right thing” (Bromiley 2011) Workgroup/Team Structures & processes (Flin, Patey 2012)

32. Examples in healthcare… Prescribing and dispensing Hand-over/hand-off information Movement of patients Order of tests Preparation of medication If all of the processes associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.

34. Systems thinking - The patients perspective? Organisational/ departmental boundaries • Value for the patient • Hand-offs • Accountability for the end-to-end experience • Job roles E B C D A Emergency care process Diagnostic process Treatment process

35. Aggregation of marginal gains • Small improvements in a number of different aspects of what we do can have a huge impact to the overall performance of the team • Sir Dave Brailsford - Performance director of British Cycling and the general manager of Team Sky. Don’t try to fix the whole system! Improve 100 things by 1%

36. Scenario 2 • Read the summary of the GP (comms errors) incident • What would you do to minimise its occurrence in future?

37. Making it easier to do the right thingPDSA example: Christopher Toilet training Aim: Christopher to urinate into the toilet bowl 100% of the time by 30th June 2010.

38. PDSA template 

39. Example: DSA Do Christopher thought the demonstration amusing and ignored it Study 0% compliance with the new process 0% reliability level Act Seek out ideas, develop new test cycle.

40. Example: next PDSA cycle A Human Factors approach! http://www.amazon.co.uk/toilet-training-target-stickers-Happeedays/dp/B002GZAWUK/ref=pd_sim_by_3

41. Human Factors & remote islands considerations Mark Johnston Training and Research Officer (Patient Safety) NHS Education for Scotland mark.johnston@nes.scot.nhs.uk 0131 656 3258 Culture Workspace @markjohnston71 http://t.co/aSIEwiGD8n Behaviours and Abilities Adapted from Catchpole