High Reliability / Human
Factors
Chris Hancock & Mike Fealey: Programme Managers, 1000 Lives
Plus
Acknowledgement
• Kind thanks to Atrainability for some of
the info and slides contained in this
presentation
Working Together
Rollercoaster
Mortality
• 1 in 1.5 billion chance of being fatally
injured at an amusement park
• Injury rates for golf and deckchairs are
higher
– US Consumer Product Safety Commission
(2007)
Hospital Mortality and
Harm• There is a one in 300
chance of accidental death
through errors in care. (Institute of Medicine, 2000)
• More than one in ten
people admitted to hospital
are harmed unintentionally
by its care. (Vincent et al. 2001)
• 11859 adult
preventable deaths
in hospitals in
England• Horgan et al 2012
Patient Safety
3,283 patients dead through preventable error, another 7,000 suffer severe harm
Equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year……
…..in the UK!
Shall We Save 100 Lives
www.1000livesplus.wales.nhs.uk
Mid Staffs Questions ...
• What are the warning signs that a hospital (or
any other part of the NHS) is in trouble?
• Why did so many senior staff in giving evidence
express their horror that they had not known
about the poor care on many of the wards?
• Is Stafford a classic case of organisational
blindness?
• The question I want you to keep asking
yourselves as we relay the story is, ‘Could it
happen on my patch? Could it happen in my
hospital and how would I know?’
– Prof Edwards 2012
Hands up
Who comes to
work to harm
people?
So who’s fault is it?
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• Now take a minute per question to
come to agreement on each table
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Pattern recognition
• Aoccdrnig to a rscheearch at Cmabrigde
Uinervtisy, it deosn‘t mttaer in waht oredr the
ltteers in a wrod are, the olny iprmoatnt tihng
is taht the frist and lsat ltteer be at the rghit
pclae. The rset can be a toatl mses and you
can sitll raed it wouthit porbelm. Tihs is
bcuseae the huamn mnid deos not raed
ervey lteter by istlef, but the wrod as a wlohe.
The Gap Between
Perception and
Practice
What We Think We Do
Vs.
What We Actually Do
Mitchell Levy,
Director, Surviving Sepsis
Campaign
• Human error is a natural consequence
of being human
Power of memory
Working Together
Working Together
Who are the best multi-taskers?
Working Together
Working Together
Working Together
Human cognition
Working Together
..and the result is..
Working Together
Stress – how full is your bucket?
Working Together
TOP TIPS
Beware
• Hungry
• Anxious / angry
• Late
• Tired
Working Together
It is important not to blame individuals for what went wrong but to understand why, what they did at the time, made sense to
them.
‘Just Culture’ - Dekker - 2007
High risk situations for
error
• Interruptions and distractions
• Tasks required out of normal sequence
• Unanticipated new tasks
• Multitasking.
Why Errors HappenFactors making error/violation more likely
• Fatigue
• Stress
• Illness
• Overload
• Inexperience
• Complacency.
Problem types
• Care Delivery Problem
– Direct provision of care, problem arises in
the process of care usually actions or
omissions by staff- Active Failures
• Service delivery problem
– Absence of guidance to enable actions to
take place- Latent Failures
The First Law of
Healthcare Improvement
“It is not bad people but bad systems that harm and kill our patients”
Source: Don Berwick, IHI (Boston)
Reliability
• Achieving reliability means doing the
right thing for every patient every time
Human Factors
• Making it easier to do the right thing
Human Factors
Approaches
• Make communications visible
• Decrease reliance on vigilance – error
proof
• Avoid reliance on memory - use prompts
• Simplify processes – SOP
• Use checklists
• Standardise
Make communications highly
visible
Decrease the reliance
on vigilance – error
proofing
Avoid reliance on
memory – use prompts
Review and simplify
processes – standard
operating procedures
Routinely use
checklists
Standardise common
processes and procedures
NEWS card & iPhone App available
Summary
• It is not bad people but bad systems that cause harm and death
in healthcare – human error is inevitable
• Most error in healthcare is due to system rather than individual
failure
• Every system is perfectly designed to achieve the results that it
gets – use human factors thinking
• You cannot achieve reliable outcomes without first achieving
reliable processes
• You have 1 job with 2 roles
– Doing your job
– Improving your job
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