Situation Awareness

Decision Making

Leadership CommunicationTeamwork

PatientStatusPlan

Human factors

Situation awareness &Mental models

Decision Making

Communication Assertiveness& Teamwork

Leadership & Task Management

Wrap Up

ERROR &HUMAN FACTORS

JUST A ROUTINE OPERATION

The real problem isn’t how to stop bad doctors from harming, even killing, their patients. It’s how to prevent good doctors from doing so.

Gawande The New Yorker 1999What happens when a team of experts gets “lost in the fog”…

Describe the experience & skills of the theatre staff ; doctors & nurses

Why did the doctors not “hear” the nurses?Why did the nurses give up?Why did the doctors persist?Why did they not take her to ICU?Who was the leader?What was their awareness of their situationWhat was their plan?

These are human factors or ‘non technical skills’

DISCUSSION

To err is humanAlexander Pope, 1711

James Reason, 1990

Institute of Medicine, 1999

ERRORS DUE TO HUMAN FACTORS ARE UNAVOIDABLE

HIGH TECHNICAL PROFICIENCY CANNOT GUARANTEE SAFETY

Analysis of 27,370 occurrences (Jan 02 – June 08) 25 wrong patient & 107 wrong-site procedures Significant harm inflicted in 5 wrong patient & 38 wrong-

site procedures Main causes wrong patient procedures

Errors in judgement (56%) Errors in communication (100%)

Main causes wrong-site procedures Errors in judgement (85%) Lack of ‘time-out’ (72%)

Equal occurrences non-surgical and surgical procedures

Wrong-Site and Wrong Patient Procedures in the Universal Protocol Era: Analysis of a Prospective Database of Physician Self-reported Occurrences. Stahel, P. Sabel, A. Victoroff , M. et.al. Arch Surg. 2010: 145(10):978-984.

HUMAN FACTORS CAN HELP EXPLAIN ERROR

REASON: CLASSIFYING HUMAN FAILURE

Human failures

Errors

Skill-basedUnintended

Slips of Action

Lapses of memory

MistakesIntended

Rule-base

Knowledge based

ViolationsIntended

Routine

SituationalExceptional James Reason

REASON: SWISS CHEESE

REASON SWISS CHEESE

Surgeon Anaesthetist Scrub nurse Anaesthetic

nurse/assistant Other (managers etc.)

HUMAN FACTORS APPLY TO ALL TRIBES & CULTURES

Consultant Registrar Resident Registered

nurse Enrolled nurse Student

Australian European African Asian Indian

Teamwork

Men

tal M

od

el

Situation Awareness

Communication

Task A

ssis

tan

ce

Graded assertiveness

LeadershipDelegation

ISB

AR

Debrief

Briefs

Decision Making

STEP

Feedback

Cro

ss M

on

itori

ng

Role

s

Hu

dd

le

Check Back

CallOut

CoachingMutual support

HUMAN FACTORS OVERLAP

HUMAN FACTORS CAN BE GROUPED

Situation Awareness

Decision Making

LeadershipCommunicationTeamwork

PatientStatusPlan

QUESTIONS?

Human factors: Is a science Describes how mistakes & errors occur Predicts behaviours that can reduce error and/or

decrease the harm resulting from error

These behaviours can be arranged into overlapping Categories: Situation awareness Decision making Communication/Teamwork Leadership/Task management

SUMMARY: HUMAN FACTORS

Situation Awareness

Decision Making

Leadership CommunicationTeamwork

PatientStatusPlan