quality education for a healthier scotland multidisciplinary the nature and reality of working...

Quality Education for a Healthier Scotland

MultidisciplinaryThe nature and reality of working safely

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

mark.johnston@nes.scot.nhs.uk0131 656 3258

@markjohnston71

Quality Education for a Healthier Scotland

Multidisciplinary

Ergonomics and Human Factors

• Known as Human Factors in the United States, everywhere else Ergonomics; they mean the same thing!

• Ergonomics from the Greek – Ergo “Work” and Nomics “Laws of”Therefore the discipline is concerned with the laws that govern human work.

• Uses methods to evaluate human work in order to optimise well-being and performance of individuals and organisations

Quality Education for a Healthier Scotland

Multidisciplinary

You’re amazing!

Quality Education for a Healthier Scotland

Multidisciplinary

Quality Education for a Healthier Scotland

Multidisciplinary

Factors impacting on an individual that contribute to error

• Stress• Fatigue• Illness• Hunger/Thirst• Hazardous attitudes• Language and cultural factors

These are NOT Human Factors, these are the consequences of not adopting Human Factors.

Quality Education for a Healthier Scotland

Multidisciplinary

Human FactorsA common language

“…the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human well-being and overall system performance.”

International Ergonomics Association

Cognitive

Organisation

Physical

Human

Quality Education for a Healthier Scotland

Multidisciplinary

Domains of Ergonomics and Human Factors

Physical ergonomics - human anatomy, anthropometry, physiological and biomechanical characteristics as they relate to physical activity.

Cognitive ergonomics - mental processes, such as perception, memory, reasoning, and motor response, as they affect interactions among humans and other elements of a system.

Organisational ergonomics - sociotechnical systems, organizational structures, policies, and processes.

Quality Education for a Healthier Scotland

MultidisciplinarySummary

Key points

• Ergonomics and Human Factors mean the same thing

• The Twin aims are enhanced well-being and performance of individuals and organisations

• These aims are interdependent• It is a scientific discipline; 4yr degree course +

practice + specialisation

Quality Education for a Healthier Scotland

Multidisciplinary

Bad people?

Errors occur due to system design and how those designs influence behaviour

Why do errors happen?

Quality Education for a Healthier Scotland

Multidisciplinary

Even experts err

Quality Education for a Healthier Scotland

MultidisciplinaryThe dilemma of “human error”

If 1 event out of 100,000 goes wrong, humans are assumed to be responsible in 80%-90% of cases

It follows that

If 99,999 out of 100,000 events go right then humans are responsible in 80%-90% of cases

Which outcome results in investigation?

Quality Education for a Healthier Scotland

Multidisciplinary

Inaction, Breach, Violation, Loss of Situation Awareness – all are just substitute terms for ‘Human Error’

• Human Error is not the cause• Human Error is a symptom

Quality Education for a Healthier Scotland

MultidisciplinaryCaptain Hindsight

https://www.youtube.com/watch?v=opfXmYlTotc

Quality Education for a Healthier Scotland

Multidisciplinary

Why don’t we (usually) bump intoeach other?

Quality Education for a Healthier Scotland

MultidisciplinaryOur response...

Safety 1 – focuses on what went wrong and tries to control by introducing further restriction

(pre work view - little or nothing goes wrong, contradicted by

hindsight)

Safety 2 – facilitating the performance adjustments that are necessary for everyday work to succeed.

People not systems are intrinsically safe!

Quality Education for a Healthier Scotland

Multidisciplinary

So….handwashing. How is that going for you?

What for you is the front line reality of trying to implement those guidelines and best practice? Safety 1

Would a safety 2 approach help?

Quality Education for a Healthier Scotland

Multidisciplinary

Tips for Safety 2

• Look at what goes right, as well as what goes wrong• Things do not go well because people simply follow the

procedures. Things go well because people make sensible adjustments according to the demands of the situation. Find out what these adjustments are and try to learn from them

• Work is Vs work as imagined (do people follow the rule all the time?)

• A small improvement of everyday performance may count more than a large improvement of exceptional performance

• Allow time to reflect, to learn, and to communicate (Be mutually accountable)

Adapted from Van Stralen

Quality Education for a Healthier Scotland

MultidisciplinaryIt goes right more than it goes wrong

• Celebrate that• Be curious as to why• Change Culture? Choose your attitude.

Quality Education for a Healthier Scotland

MultidisciplinaryThe nature and reality of working safely

Mark JohnstonTraining and Research Officer

(Patient Safety)NHS Education for Scotland

mark.johnston@nes.scot.nhs.uk0131 656 3258

@markjohnston71