Human factors in patient safety
'Human factors' refers to a theory of the relationship between human behaviour, system design and safety that is becoming increasingly influential in helping us understand the causation of errors, accidents and failures in health care systems. An understanding of the core elements of human factors theory will enable you to improve the safety and effectiveness of your own practice.
Basically, human factors issues are any environmental, organisational and job factors or indeed, human and individual characteristics that influence behaviour in the workplace and which can be implicated in the development of errors and accidents. They are concerned with what people are asked to do, where they are asked to do it, who is asked to do it, and what kind of organisation they are working in.
What people are asked to do
The focus here is on the job or task. Errors can occur when people are asked to perform tasks or do jobs for which they are neither trained nor competent or for which standard policies and procedures are either absent or out of date. They can also arise because the task or job has become so commonplace or regular that it seems routine or can be 'done without thinking'.
Where they are asked to do it
The environment in which services are delivered is very important. Factors such as adequate light, heat and ventilation, attention to the condition of equipment and workplaces and robust maintenance and repair processes are necessary to support safe practice.
Who is asked to do it
Individual knowledge, skills, experience, attitudes, risk awareness and relationships with fellow workers and patients will influence how health care workers behave in work settings.
What kind of organisation
Organisational culture will largely determine acceptable standards of work, work patterns and flows, leadership and management behaviours and communication and accountability mechanisms.
The human factors theory therefore acknowledges that people and their behaviour are influenced by many factors – task-related, environmental, personal and organisational. It acknowledges that humans are fallible and will always be prone to errors, but that organisational and environmental issues can and do compound that fallibility.
Explore the 'Human Factors Model' below. It is a suggested model for helping you to bring to mind the 'human' elements that are constantly changing and interacting with each other to contribute to both safe and unsafe patient safety situations. As you consider the model, imagine a task you perform on a regular basis in your practice. Think about how each of the elements can be affected by each other to make the outcome of that task safe or unsafe. Take each element individually - what happens if something is wrong with one element? Now think about what happens when something impacts on two elements, and then all three - the perfect storm of a patient safety incident!
You may find it revealing to revisit the scenarios in this learning resource and keeping this model in mind, focus on how these human factor elements were compromised and contributed to the poor outcomes for these patients. You may wish to use the 'Reflective record' template in the 'Taking action' section to document your thoughts and print/save it as evidence of your continuing professional development for your professional portfolio.
The benefits of applying human factors in health care
Awareness of human factors such as those above can help you to:
- understand why staff make errors and which factors threaten patient safety
- improve the safety culture of teams and organisations
- enhance teamwork and improve communication between staff
- improve the design of health care systems and equipment
- identify what 'went wrong' and predict what 'could go wrong'
- appreciate how certain tools can help to lessen the likelihood of patient harm (Patient Safety First, 2010).
Human factors systems analysis provides a way to identify where potential errors may arise. This requires specialist expertise, but there are short exercises you can do to increase your systems awareness and apply human factors principles to ensuring you are working safely. In the 'Useful resources' section you can access an article called, 'Human factors and safe patient care', by Beverley Norris which sets out one such process.