For more than two decades, experts have been pleading for the human factors lessons learned from aviation safety to be applied to the growing toll of iatrogenic injuries in medicine. Now a new set of guidelines aimed at reducing the risk and potential impact of human error in surgery has been developed by a working party of the Difficult Airway Society and the Association of Anaesthetists, supported by the Royal College of Anaesthetists and other national organisations.
Co-author Dr Fiona Kelly, consultant in anaesthesia and intensive care medicine at the Royal United Hospitals Bath NHS Foundation Trust, explained: "The new guidance has analysed all the potential areas in anaesthesia where human error can creep in with potentially devastating outcomes, and is likely to be applicable to other healthcare specialities."
Human Performance May Fail in High Pressure Situations
The guidelines, published in Anaesthesiaalong with a review article by the authors, and presented at a special session of the winter scientific meeting of the Association of Anaesthetists in London from 12-13 January, draw on 'human factors' principles and strategies that have been successfully incorporated into other safety critical industries, including aviation, nuclear power, offshore oil and gas, construction, rail, and the military. They acknowledge that as many as 1 in 10 patients may be harmed by their interactions with the health service.
"More than ever, there is a need to strengthen systems ensuring patient safety and to reduce the impact of human error in health care," the authors said. They said that release of the guidelines is timely given that the NHS is currently being "brought to its knees" by what they described as "a perfect storm of difficulties", including long ambulance waits, crowded emergency departments, and hospital throughput delays at a time of peak winter respiratory illnesses combined with pre-existing staff shortages and strikes by medical personnel.
"Human factors can be addressed in all parts of the healthcare system to reduce the risk and impact of human errors and adverse events", the authors said. The 'human factors' approach is "an evidence-based scientific discipline used in safety critical industries". They suggested that their guidelines, which have been 5 years in development, would be suitable for clinicians, departments, hospitals and national healthcare organisations – "to enable them to design and maintain safe systems that will reduce the risk and potential impact of human error by individuals or teams".
The researchers noted that healthcare relies on high levels of human performance, but that this is variable "and is recognised to fail in high-pressure situations" – meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is the potential to do the same in anaesthesia particularly, and in healthcare more generally.
"We are not only discussing avoidable deaths here, but also long-term consequences in patients who survive when avoidable errors and adverse events occur," said Dr Kelly. The human factors approach "aims to make it easy for workers to do the right thing, and difficult, or ideally impossible, for them to do the wrong thing".
Moving 'Human Factors' Into Everyday Practice
Co-author Professor Chris Frerk, consultant anaesthetist at Northampton General Hospital and the University of Leicester Medical School, and chair of the Clinical Human Factors Group (a charity dedicated to making healthcare safer), said: "Care given within the NHS has become increasingly complex over the last 20 years, and is now delivered by teams of nurses, physiotherapists, pharmacists, doctors, and other support staff. As many as 1 in 10 patients are harmed during their interactions with the NHS; this is not because staff don't care or don't try hard to do the right thing. The old model of healthcare where we assumed that having knowledge (and experience) about the heart, lungs, cancer, or arthritis would be enough to keep patients safe is just not the case anymore.
"Adopting a 'human factors' approach across healthcare, to eliminate the risk and impact of human error, has been on the national agenda for more than 10 years. With this guidance, we want to start to move this approach into everyday practice for everyone in the NHS."
The guidance comprises 12 recommendations that address issues, including: training; education; the design of medical equipment and operating theatres; using the most effective equipment; effective use of checklists before operating; encouraging staff of any seniority to speak up if they have safety concerns; the ability to learn from situations where things have gone wrong, sometimes fatally so, and also from situations where things have gone well.
Design Factors Most Effective Safety Measures
Design of the environment, equipment, and systems is the strategy likely to be most effective, the authors explained. 'Designing out' the chance of an error occurring "reduces the requirement for exceptional human performance commonly relied upon in healthcare". Examples of design recommendations included:
- Design and procurement of medical equipment should include input from human factors experts at an early stage, when changes are still possible
- Drug ampoule and packaging design should incorporate human factors principles to optimise readability and reduce the risk of mis-selection, for example favouring generic drug names, making the drug name more prominent than the manufacturer's name and logo, and standardising the use of colour
- Incorporating human factors in the design of safe working environments with regular reviews to ensure that safety has not been compromised.
The next most effective strategies, in order, are: Barriers, to 'trap' errors to prevent them progressing; mitigations, to reduce the consequences of errors (such as analysis of deaths or critical events); and education and training. However, the authors explained that the current UK healthcare system gets all this upside-down, with heavy reliance on high levels of human performance and a resultant small and unstable foundation for safety.
Finally, they said that improving human factors is in no way a substitute for proper funding and resourcing of hospitals and healthcare systems. "Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped."
The Difficult Airway Society and Association of Anaesthetists funded the meetings of the Working Party and SurveyMonkey subscription.