Situation Awareness Decisi on Making Leadership Communicatio n Teamwork Patien t Status Plan Human factors Situation awareness & Mental models Decision Making Communicati on Assertivene ss & Teamwork Leadership & Task Management Wrap Up ERROR & HUMAN FACTORS
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Human factors Situation awareness & Mental models Decision Making Communication Assertiveness & Teamwork Leadership & Task Management Wrap Up ERROR & HUMAN.
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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