The healthcare industry is gradually recognising the benefit of human factors engineering when introducing safety systems. Traditionally there has been a reliance on solutions that increase staff members accountability (policies, protocols, guidelines).
The overwhelming majority of healthcare staff are extremely conscientious and hard working, however they will still make mistakes.
‘It is human to err.’
We must aim to ensure that when these inevitable errors occur they do not lead to patient harm. Below is a selection of useful resources reviewing how human factors can improve safety in health care:
The Hierarchy of Intervention Effectiveness – This diagram neatly shows the effectiveness of different types of intervention.
‘Never events’ or ‘Always Conditions’ – great post from Steven Shorrock explaining how use of the term ‘never events’ may actually be detrimental to safety improvement.
Black Box Thinking by Matthew Syed – a fantastic must read book.
Team of Teams – General Stanley McChrystal et al. An excellent book discussing how we need to move on from command structures of management if patient safety is to improve in our complex health care environments.
What is human factors engineering? – series of slides discussing human factors
The Problem With Root Cause Analysis – BJA Quality and Safety
Improving the Safety of Patients in England – The Berwick Report
Adaptive Learning – Prof Ron Heifetz – a must for anyone attempting to drive change.
How to Win Friends and Influence People – Dale Carnegie – despite it’s title and it’s age this book provides great insight into how leaders might choose to conduct themselves.
Errors in Medicine: A Human Factors Perspective – Gaylene Heard – Excellent article, a must read.
Clinical Excellence Commission (Human Factors Page) – Web link to valuable resources from CEC, including PDFs of presentations given by Terry Fairbanks.
Medical Human Factors – Videos
Just Culture by Sydney Dekker – Looks at how to balance safety and accountability.
Hinds: Crack the Chest. Get Crucified – Video illustrating what often happens in healthcare when you try to implement change.
Safety Differently – Brilliant video from Sidney Dekker describing how if we want safety to improve we need to do it differently.
Great post discussing how ‘Key Performance Indicators‘ are detrimental to patient care