Authors: Charlotte Davies / Editor: Lucine Nahabedian / Codes: SLO11, SLO2, SLO4 / Published: 07/02/2023

Human Factors (HF) is a term that’s often used when talking about events that happen in the emergency department, and many people, including us, had a lack of awareness of the full scope of human factors, and how it applies to emergency medicine. SLO11 in our new curriculum specifically says “Understands basic Human Factors principles and practice at individual, team, organisational and system levels”. SLO2 says “be aware of the human factors at play in clinical decision making and their impact on patient safety” and SLO4 says similarly be “Aware of the human factors at play in clinical decision making and their impact on patient safety” as well as “Aware of Human factors/non-technical skills that affect performance of team caring for trauma patient”. So here is a brief run through human factors, and how it applies to us in ED. There’s also a RCEMLearning reference guide covering similar topics.

So, firstly, other than the curriculum, why is it relevant? Well, if you all think back to a mistake you’ve made, or when a bad thing happened in your department, could you honestly say there were no human factors involved? The way we investigate these incidents is changing. Healthcare Safety Investigation Branch (HSIB) uses human factors methodology to investigate errors, and are strongly encouraging all hospital trusts to follow suite. As such, there are lots of training resources available. Many serious incidents investigations nationally (CQC 2016) and locally cite “human error” as the root cause of the incident, with the resulting view that recurrence cannot be prevented, or mitigated.

So… a definition. There are lots of definitions we could use. The concept of HF is introduced to most healthcare staff by simulation training, where a simulated scenario is watched, and the HFs are explored by a debriefer who may or may not have advanced knowledge. Simulation is often considered an answer to enhancing safety, where HF contributions are not just identified, but management strategies are also suggested by the debriefer. This highlights a generally held belief in healthcare that HF covers “the HF”, concentrating on a person-centered approach to safety (Rutherford 2020). “Just a routine operation” by Martin Bromiley (undated) is considered to be the stimulus for introducing HF into healthcare, and is a video that is played at most simulation courses. This video names awareness, communication, decision making, shared decision making, leadership, prioritisation and assertiveness as contributory factors to an adverse event. It is, therefore, unsurprising that these “non-technical skills” have been confused as the complete set of HF. HF evolved from a series of isolated topics eventually being joined together, and healthcare is following a similar timeline in its understanding of HF (School of Health and Social Care 2020). 

HSE Definition: “Human factors refer to environmental, organisational and job factors, and human and individual characteristics, which influence behaviour at work in a way which can affect health and safety.”

WHO Definition: Human factors examines the relationship between human beings and the systems with which they interact by focusing on improving efficiency, creativity, productivity and job satisfaction, with the goal of minimizing errors. A failure to apply human factors principles is a key aspect of most adverse events in health care.

HEE Definition: Human factors principles aim to understand the ‘fit’ between an employee, their equipment and the surrounding environment, which can include learning styles, behaviours and values, leadership, teamwork, the design of equipment and processes, communication and organisational culture.

CIEHF Definition: “Ergonomics is the scientific discipline concerned with the understanding of interactions among humans and other elements of a 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: The terms ‘ergonomics’ and ‘human factors’ can be used interchangeably, although ‘ergonomics’ is often used in relation to the physical aspects of the environment, such as workstations and control panels, while ‘human factors’ is often used in relation to wider system in which people work.

So you can see there is no single accepted definition of human factors, but it makes sense to use the Chartered Institute of Ergonomics & Human Factors definition. All of these definitions refer to human factors as being around interactions, and systems. They are more than just non technical skills.

What is a System? 

There can be systems within systems and you all know that the emergency department is a system, within the wider system of the hospital, in the trust, in the NHS. The first step is to define the system you are investigating – which might seem easy, but isn’t. We had a look at our system around blood labelling in ED, and mapped the patient journey, so we could know what happened. This is part of understanding work as done vs work as imagined – and we all know the two are very different. 

Fig.1

Or you could display tasks as a hierarchical task analysis, in graphical or tabular form.

Fig.2

And this shows what happens. Other task mapping items exist- you’ll all be familiar with the timeline approach used in incident investigation. An AcciMap can also be used but is graphically difficult.

We then need to map out the interactions in the system, and there are lots of tools you can use to do this. One of the most popular ones is the SEIPS.

Fig.3 via HSIB

This can be graphically displayed as below or written in tabular form. This starts to look at mapping every element of the process onto components that affect it. It is, I believe, this mapping and looking at a whole system approach that makes a human factors methodology unique. Fixing our printers reduced our blood mislabelling.

Fig.4
Fig.5

Each area of the SEIPS model can then be looked at in detail to sub-analyse and to see where to improve. A recent HSIB report looked into themes appearing in several of their investigations – we probably all know staff shortages and fatigue contribute to every incident, but design and working environment etc. contribute to many too. Again, these are more than the non-technical skills – they focus on the interactions and the systems, not just the person.

Fig.6 via HSIB

Other system mapping tools exist, especially in healthcare – the “SHEEP model”, and the “Yorkshire Contributory Factors” (worked example in the aorta blog here) but they all follow roughly this layout. The FRAM model is also useful. 

 

 

 

Changing the Problem

Identifying the problem is only half of the challenge. We then need to change it.  The hierarchy of control (HSIB) picture suggests that elimination is always better than substitution. You know this – some of you may remember cash machines used to give you your cash (remember that?!) and then card. So everyone left their card behind. They introduced a forcing function and gave people their card, then their cash. Problem solved. We need forcing functions in medicine – but management tactics are often useful too.

Some do exist – a guidewire that can’t be retained.

Some use design to help – an obs machine that records, retracts, cleans and has a timer to prompt you for respiratory rate.

Fig.7

What ideas can you think of?

Non-Technical Skills

We know now our old iBook on “Human Factors” was erroneously labelled  – but for more information on the non-technical skills including tips on how to improve them, please read the iBook, and send us your tips and hints.

Design & Environment

There are lots of clever designers out there, and some guidelines on how to design a hospital. The key reminder is to think about human shapes and sizes (everyone matters – send your measurements to the CIEHF so we can have representation).

In a trauma call – how many people fit round your cubicle? Here doctor three only fits in if they are about 2cm thick as the bed is too close to the wall. It’s a tiny impact on performance – but every little helps. This is explored further by EM Cases here.

Fig.8

The government’s health building notes assimilate much of the design knowledge for you – if you are redesigning any cubicles, and haven’t already, have a look at them, although I’m not sure how well most emergency departments would do on the “quality of life” checklist (HBN 03-01 – Adult acute mental health units)! Design isn’t about making things look pretty – it’s about “healing” with the “hospital environment” – so many ideas in “Healing the Hospital Environment”.

We know noise is bad for you, and many improvement projects have tried to reduce it – yet it persists, even though the ED hospital building note makes many suggestions for mitigating noise, including curved bed heads. RCEM even have a document on designing the smartest ED which lists how to make departments safer for the elderly including matt floors, clocks, colour coding but also highlights how until you’ve mapped your system, you don’t know what you need – junior doctors are at the “nurses station” 51% of the time, and in the bays only 39%.

Fig.9

High noise levels are evidenced to:

  • reduce speech intelligibility, especially in children and those over 40,
  • increase annoyance and aggressive behaviour
  • exacerbate latent mental health illness
  • reduce reading ability,
  • reduce helping behaviour and impaired teamwork
  • exacerbate hypertension and perhaps cause pneumothoraces
  • contribute to error generation
  • interfere with communication
  • reduce cognitive ability

 

So how do we reduce noise? By looking at a systems based approach, we made a few suggestions that “force” noise reduction, and last longer than an awareness campaign, as full of merit as that is.

Fig.10

But what about the design of our everyday experience? The design council looks at how medication packaging etc. is designed without an awareness of its use – you could almost say, without an awareness of human factors. If instead, we designed out medical error, making sure all equipment was accessible, things could be a lot safer. But to do so, we need to think about human factors. 

Human Error and Risk

Human Factors also provides us with tools to predict risks before they happen. Tools like the “Goals, Operators Methods and Selection Rules (GOMS)” approach, or verbal protocol analysis could be used. A human error HAZOP approach (Stanton, 2013, p. 176) is easy to use, and this is where each step in the process, as determined by the HTA, is considered in conjunction with a guide word. Guide words can be personalised, but the key words are normally “not done” or “part done”. You can see below that with regards to blood transfusion, you can consider what would happen if blood not prescribed correctly.

Fig.11

Just Culture

It is hard to separate risk and incidents from human factors. Using a human factors approach to any incident investigation really highlights how it’s never just one thing. The “Just Culture” strategy really highlights how in order to maintain safety, we need to be just and fair.

So, has this convinced you everyone needs more Human Factors training? Make sure you read the 12 top tips on how to embed HF into your training. Helen Vosper, Sue Hignett & Paul Bowie (2018) Twelve tips for embedding human factors and ergonomics principles in healthcare education, Medical Teacher, 40:4, 357-363, DOI: 10.1080/0142159X.2017.1387240

Maybe time to hire an expert!