FEBRUARY 2023
EDITION 22
HUMAN FACTORS: THE FILTHY FIFTEEN
Human factors refers to the interrelations between the environment, the job and the organisation in which the work is being carried out. Human factors was first identified in aviation and other high-risk industries as being important to consider in order to prevent or mitigate incidents, accidents or near misses. The role of human factors has become important in the healthcare setting as we know that people carrying out their roles can unintentionally contribute to safety incidents occurring, whether it be a medication incident, a patient fall or an incorrect procedure. This is important when we are looking at causes which contribute to incidents happening. Gordon DuPont, a highly respected aircraft engineer, described twelve factors that contributed to accidents or incidents in the airline industry but could equally be applied to the healthcare industry or other high-risk industries. These were referred to as the “Dirty Dozen” (1993) In 2014, Boeing added a further three possible contributing factors and the fifteen are now referred to as the “Filthy Fifteen” . The Filthy Fifteen are outlined below and will be expanded on further over the next few issues of Foresight 1
Complacency
Pressure
Stress
Lack of operational integrity
Distraction
Fatigue
Lack of professionalism
Lack of communication
Lack of assertiveness
Lack of Awareness
Not admitting limitations
Lack of knowledge
Lack of resources
Lack of teamwork
Norms
The expansion to the Dirty Dozen becomes the Filthy Fifteen (Boeing – 2014)
The original Dirty Dozen (Gordon Du Pont, 1993)
The potential precursors to accidents, incidents or elements that can influence people to make mistakes. The aim of the concept is to focus attention and resources towards reducing and capturing human error.
Complacency – So self-satisfied that we lose awareness of dangers. Distraction – Anything that takes your mind off the job at hand even for an instant. Fatigue – Lack of sleep or extended wakefulness. Lack of assertiveness – saying yes to something you should say no to Lack of awareness – One of the safety nets for lack of awareness is to ask more “what ifs” when there is conflicting information or things don’t quite seem right. Lack of communication – Abbreviations, voice, tone, intonation Lack of knowledge – With constantly changing technology, this contributor is more common than we think Lack of operational integrity – Can result in risk taking behaviour Lack of professionalism – When staff choose to do things their way, are rude or behaving badly or simply do not have pride in their work. Lack of resources – Has contributed to many incidents. Lack of teamwork – Team dynamics may vary dependent upon whether team members are well known to one another, or whether they are a transient team which comes together for specific tasks. Norms – Can be unwritten rules that are enforced. Not admitting limitations – Hasn’t received adequate training on something but has so much experience, they can “figure it out.” Pressure – To be on time is ever-present. Most industries are time-sensitive and many decisions centre around that fact. Stress – We all have some stress in our lives, and it is not all bad unless it becomes excessive.
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Clinical Governance Standard
Contact: NSLHD-SQEP@health.nsw.gov.au
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