How human factors in healthcare contribute to avoidable harm

“How do we design and operate a system which has relatively inconsistent human beings at its core?”¹

Dr Tim Kane, Co-Director and Founder of Practical Patient Safety Solutions (PPSS) and Consultant Orthopaedic Surgeon at the Portsmouth NHS Trust, UK, dove into the complexity of this question in his presentation at the BD Multidisciplinary Advanced Course on Vascular Access (MACOVA) 2022.

Human factors in healthcare play a major role in the quality of treatment patients receive, and Dr Kane reinforced this by presenting 12 cases where patients died due to preventable errors.¹

So, how do we standardise a system populated by individuals that perform, according to Dr Kane, inconsistently and unreliably?¹

The reality of preventable patient harm

According to the Organisation for Economic Cooperation and Development (OECD), more than 10% of patients are harmed during care.² Moreover, 12% of preventable patient harm causes permanent disability or death.³

From 1st April 2018 to 31st March 2019, the UK National Health Service reported 496 “never” events, defined as incidents that “should not occur if healthcare providers have implemented existing national guidance or safety recommendations.”⁴

More recently, from 1st April 2022 to 28th February 2023, 356 “never” events were reported.⁵

“What are the consequences of this?” asked Dr Kane.¹ “Well, it’s really widespread.”

Patients and their families are the primary victims, but staff, the reputation of healthcare providers and institutional finances all suffer alongside them.¹

Concerning the latter, 15% of all hospital expenditure and activity in OECD countries can be attributed to treating safety failures.⁶

Human factors in healthcare: Designing errors out of the equation

They key to preventing harm to patients and avoidable errors is understanding the psychology of error, said Dr Kane, and this is the central idea behind human factors science.¹

Dr Kane quoted the Charter Institute of Ergonomics & Human Factors, who defined the approach as, “helping people to do the right thing and to make it impossible or hard to do the ‘wrong thing’ by designed out the potential for making mistakes.”¹

Human factors in healthcare include not only psychology, but communication, team resource management, human-machine interfaces (liveware-hardware) and human-software interfaces (i.e., procedures, paperwork, labelling).¹

It comes down to a systems-based approach, said Dr Kane, and high reliability organisations provide an insightful example of how healthcare institutions should function to prioritise preventing avoidable errors.¹ A high reliability organisation, Dr Kane characterised:¹

• Learns from near misses and accidents through root cause analysis (RCA)
• Creates and uses robust, system-wide standard operational procedures (SOPs)
• Trains staff on the “why” and “how” behind those SOPs
• Monitors staff compliance and conditions at the front line

It’s a shift away from blame culture; instead of looking at the individual involved in the error, the fault is placed on the system itself.¹

“No high reliability organisation would use a term like a ‘never event’ when things go wrong,” said Dr Kane. “It’s a finger-pointing exercise and it very much distracts from the shared responsibility and the learning you can get.”¹

Learn more about high reliability organisations: How to improve the reliability of healthcare, from Sir David Dalton

About BD MACOVA 2022 

BD MACOVA 2022 was held in Berlin on the 8-10th June and welcomed over 300 guests and 31 speakers from 35 countries.

The event carries a rich history of engaging leaders in vascular access (VA) to share their experience and insight into vascular access management (VAM) with those looking to expand the use of vascular access devices and services they provide in their hospitals.

This year’s theme was to create a VA community of VAM-bassadors (Vascular Access Management Ambassadors) of change to help improve patient outcomes.

Learn more about MACOVA 2022: Development of a vascular access team: One size does not fit all

References