Human factors: the way forward in healthcare and the personal price of failure on a 12 year old

2013 has seen a continued recognition of the critical role that human factors plays in safety science. But although aligned with the ‘safety agenda’, human factors offers so much more to an organisation: it’s about making it effective and efficient.

I recently toured a major manufacturing facility in the UK. Safety amongst very heavy pieces of kit was at the forefront of their minds. They have human factors specialists working with them but not in the Health and Safety Team, they were in the Quality Team, because they recognised that making it easy for frontline people to do the right thing reduces variability and achieves the right outcome, and is usually safer.

As part of the government response to Francis, a document was also made public by the National Quality Board, the team at the top which hold the reins on quality and safety in the NHS: the Human Factors Concordat. It was developed in conjunction with the NQB and the Department of Health Human Factors Reference Group, which has had some of the very best people in human factors and healthcare involved in it on and off for the past two years. I’d urge you to read it.

The Concordat is a 22 page document with some great examples, both good and bad, and a commitment from a number of significant organisations to do their bit to help the NHS embed best practice in human factors. No one else has ever tried to embed human factors in healthcare on a national scale across the breadth of human factors and ergonomics, from design of equipment through to systems, training, notechs, investigation and regulation.

Having a policy steer is critical because, up till now, all the evidence of human factors adoption seems to be because of the leadership and passion of certain clinicians. It’s still patchy, but once professionals see there’s a whole area of professional expertise that has been hidden from them they naturally want to know more. You can’t put the lid on the box now, it’s too late.

Of course there are whole swathes of healthcare practice to work with. So far human factors is more commonly talked about in hospital settings, but what about public health, mental health, primary care, community and social care? The threats to safety are great, but the benefits of human factors understanding potentially even greater.

When my late wife died my youngest was 4 years old. He didn’t cry for six months, and then I think he probably realised that ‘gone for ever’ really meant it. Early this year I discovered by accident that he’d written a poem as part of a school project. I share part of it here, it’s all his work:

It happened mid-April, two thousand and five,
at the age of thirty-seven.
Intensive care for several days,
then Elaine slipped away into heaven.

I remember it well, it goes like this;
Elaine Bromiley kissed a goodbye to her children.
One aged just four, the other at five,
this was ‘just’, a routine operation.

Her death was one in fifty-thousand,
however, it was nobody’s fault.
Errors are made and mistakes are learnt,
human-factors, caused the hidden assault.

There still is no day without grieving,
and mum is still in my heart.
Two children, a dad but no mummy,
and nothing, can keep us apart.

It happened mid-April, two thousand and five,
at the age of thirty-seven.
Intensive care for several days,
then Elaine slipped away into heaven…

I hope the NHS of the future will be safer because it understands the price of failing to consider human factors at all stages of the system. I believe it will.

Here’s to a safer 2014.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group, www.twitter.com/MartinBromiley