Human Factors

Read here for a brief overview of Human Factors. For a more detailed explanation please go to the Education Module.

Humans are a paradox of fallible intelligence and creativity. Man has evolved to a position where many functions are performed without conscious cognitive action, but this makes us susceptible to some fundamental limitations and errors. Some of our human shortcomings can be mitigated by design of systems, surroundings, tools and equipment and the application of restrictive rules and procedures. However we must all be aware that we are all prone to apparent lapses of ‘common sense’. Equipment and process design are a major part of human factor science as is the behavioural aspect, which is termed ‘non-technical skills’.

According to WHO, globally, 1 in 10 patients leave a hospital in a worse condition than they enter it, due to preventable medical error.

All clinicians can make mistakes. We work in very complex environments with multiple distractions and in systems that have not always been designed for safety. Traditionally our medical culture has often been ‘shame and blame” and we become unlikely to talk about error. We therefore lose opportunities to learn from and improve systems based on these mistakes. The authors of the 4th National Audit Project (NAP4) highlighted in 2011, that blame culture frequently dominates in healthcare and proposed a ‘just culture’, which aims to focus on identifying and fixing the system failures, and not tolerating reckless behaviour where safety steps are ignored.

In the Swiss Cheese Model proposed by James Reason, our defences against error are shown as a series of barriers, represented as slices of the cheese. The holes in the cheese slices represent weaknesses in individual parts of the system, and are continually varying in size and position in all slices. The system as a whole produces failures when holes in all of the slices momentarily align, permitting a hazard to pass through holes in all of the defences, leading to an accident.