APRIL 2023
EDITION 24
HUMAN FACTORS IN HEALTH
Clinical processes at the point of care e.g., assessment and examination of the patient; investigations ordered, reviewed and acted upon; observations and monitoring undertaken, reviewed and acted upon. Teams and communication e.g., interrelationships between team members, clinical handover of information among team members and between teams, working in multi-disciplinary teams, involving patients in their own care. Environmental e.g., the physical setting in which health workers perform their tasks which includes noise, design, clutter; access to senior clinicians, shift patterns, skills mix. Task, technology and equipment e.g., availability of procedures that are practical and workable; access to functioning equipment and technology; decision making aids. Organisational and management e.g., strategic planning, safety culture, models of care, workforce planning, formalising procedures, training and orientation. External e.g., NSW legislation, policy directives set at the state level, national accreditation standards, codes of conduct for health practitioners. Human factors in health is about looking at people and how they interact with each other and the healthcare system. Health workers are human beings, and like all human beings are fallible. We all make mistakes at work. Usually there is no impact, or the impact is minor. In rare cases the impact is catastrophic. Human factors involves developing ways to minimise or eliminate the potential for mistakes by looking at each of the components of the healthcare system and how they can support health workers do the right thing. The healthcare system is complex and is made up of the following interrelated components. Human factors in health encompasses all of these components that can influence health workers and their performance in the workplace.
Adapted from: Human factors and health workers, Lessons for learning, CEC July 2022
Distraction
This month we will take a more detailed look at the human factor of Distraction. Distraction can occur when our workload becomes unmanageable and we become overloaded and can make errors. What we may not always expect is during periods of low activity, we may not be as vigilant as our defenses are down and we can therefore be more prone to making errors.
Example: In healthcare, this could happen towards the end of a shift when the workload is of high intensity and then followed by a lull in activity. An important routine check of the emergency trolley was not carried out or overlooked. A patient suffered from a cardiac arrest and the required equipment was missing from the emergency trolley, and it took longer for someone to find a replacement. Resulting in a delay in treatment for the patient. This example correlates with the fact that errors often occur in routine, low workload, undemanding situations. Be aware and do not let your vigilance be reduced because the job is simple or routine.
The Filthy Fifteen
Complacency
Pressure
Stress
Distraction
Fatigue
Lack of communication
Lack of assertiveness
Lack of Awareness
Lack of knowledge
Lack of resources
Lack of teamwork
Not admitting limitations
Norms
What you can do:
Lack of professionalism
Lack of operational integrity
Plan ahead and anticipate what might come up Control distractions Talk out loud (risk triggered commentary)
Anticipate issues associated with the environment Ensure you keep well hydrated and nourished. Adopt lifestyle habits conducive to reducing fatigue and remaining alert.
Ref: Global Air Training 2022
Contact: NSLHD-SQEP@health.nsw.gov.au
Clinical Governance Standard
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