M&M, Human Factors

To err is human.
The best people make the worse mistakes.

M&M seeks to answer these questions:

1. have the right diagnoses been made?
2. have all options been considered?
3. has the patient's fitness been optimised?
4. technical / procedural aspects of treatment

In healthcare, three perennial goals:

1. Safety
2. Efficiency
3. Excellence

Being safe and efficient, while striving for the best possible outcome.

Failures in patient safety, analyse these 3 aspects:

1. The task
2. Human factors (human error)
3. Systemic factors (latent error)

The task - complexity, resources available, time limit

Human factors - skills, experience, attitudes, personality, stress, fatigue, situation awareness, decision making, team structure, team dynamics (leadership, communication, conflict, feedback)

Systemic factors - organisational culture, rules, protocols, product designs, safety checklists

WHO Human Factors Review

Health and Safety Executive, UK, Human Factors

Non-technical factors - attitudes, personality, leadership style, communication

Cognitive factors - situational awareness, decision making

Personal resources - stress, fatigue

Situational Awareness

1. What is going on? - critical cues
2. Making sense (so what?) - arriving at most likely diagnosis, formulating a course of action, taking note of available resources and existing limitations
3. Taking action (now what?) - coordinating and making use of resources to deal with the problem, anticipate and plan for the future
4. Ongoing review - taking note of changing cues and feedback, updating diagnosis and plans

Pitfalls that 'blinds' our situational awareness

• Underestimation / overconfidence
• Startle effect (stunned)
• Tunnel vision (forget about other possibilities - single-track thinking)
• Task fixation (not aware of evolving changes / other ongoing issues)
• Distractions