Making Tomorrow’s Doctors Safer

Patient Safety – the human factor

Martin Bromiley

Accidents were an unfortunate but accepted risk or complication of flying.

We know we’re not perfect...

But among the flying community it’s generally believed that ALL accidents are preventable

But among the flying community it’s generally believed that ALL accidents are preventable

....but why do we believe that?

• Investigation (technical & non-technical/HF)

• Investigation (technical & non-technical/HF)• Safety and human factors embedded from the

very first flight

• Investigation (technical & non-technical/HF)• Safety and human factors embedded from the

very first flight• Continued process of knowledge, examination

and assessment of technical and non-technical skills (Pilots, Cabin Crew, Engineers, Air Traffic Controllers.....)

• Investigation (technical & non-technical/HF)• Safety and human factors embedded from the

very first flight• Continued process of knowledge, examination

and assessment of technical and non-technical skills

• Reinforcement of the skills to balance safety and productivity

But it’s much more than just what the frontline are taught and what they do.....

It’s also about.......

• Leadership and personal example• Rules that don’t encourage rule breaking• Equipment reliability and design/ergonomics• The whole team understanding of safety and

human factors, relevant to their field

If we understand Human Factors….

We can develop techniques to optimise human and system performance using:

• Physical design of structures, tools, buildings etc• System design of process and protocol• Cognitive strategies for how we behave

In other words, making it easy to do the right thing all the time, with reliability of outcome

So to understand the human in the system, future doctors need to understand…....fundamentally, that error is normal!• How design and environmental factors influence

performance • How systems encourage or discourage doing the right

thing• The impact of our behaviour on others and vice versa –

and how we really behave!• Cognitive strategies for behaviour and thinking• Past investigations and the cost of being unsafe • The safety v productivity dilemma

Some of the CHFG “Team”over the last 4 years….

• Prof Jim Reason – Univ of Manchester

• Dr Jane Carthey – HF Specialist

• The late Prof Helen Muir – Cranfield

• Prof Rhona Flin – Aberdeen University

• Tony Giddings - Former member of the Council of the Royal College of Surgeons Eng

• Jane Reid – President, International Federation of Perioperative Nurses

• Chris Sadler – Consultant Anesthetist & Director of Barts and The London Medical Simulation Centre

• Clare Bowen

• Matthew Sargeant – Hywel Dda Health

Board, Consultant Psychiatrist • Cate Quinn – Care Quality Commission

• Prof Charles Vincent – Imperial

• The late Dr Karen Woo - BUPA

• Nikki Maran – Scottish Clinical Simulation Centre

• Peter McCulloch – QRSTU Oxford

• Linda Watterson – Royal College of Nursing

• Allan Goldman – Consultant Intensivist

• Mark Emerton – Orthopedic Surgeon

• Stephen Ramsden – Chief Executive L&D NHS Trust

• Dr Melinda Lyons & Bev Norris – HF Specialists representing the NPSA

• Hugh Rogers & Nikki Davey – representing the NHS Institute

• Simona Arena – Health Foundation

• Prof Nick Barber – Prof of the Practice of Pharmacy, Univ of London

• Emma Stanton – BAMMbino

• Sir Ian Kennedy – Chair of HCC

• Consultant Anaesthetist• Consultant Anaesthetist• ENT Surgeon• Senior ODP• ODP• Recovery Nurse• Recovery Nurse

Thank you……want to learn more about HF in healthcare?

• Charles Vincent & CPSSQ at Imperial are hosting the second “CHFG Open Seminar” on 19 April 2011. Spaces are free but limited, see www.chfg.org