Factoring the Human into Patient Safety

Rhona Flin,

Industrial Psychology Research Centre

Patient Safety Research Group

IV Conferencia International de Seguridad del Paciente

Madrid, 25 November 2008

Welcome to the Industrial Psychology Research Centre. The centre specialises in the application of psychology to high reliability workplaces.

The group has worked with the oil industry since 1986, and regularly engage in consultancy projects. We are currently working with the offshore oil industry, civil aviation, nuclear power generation, surgery, emergency services, conventional power generation and transportation.

Interests of the centre include:

•Accident analysis

•Incident command

•Occupational stress

•Emergency decision making

•Crew Resource Management

•Measuring and managing safety culture/climate

•Human factors aspects of safety management and emergency response

Clients include: Agip, AKER, AMEC, Amerada Hess, AMOCO, British Energy, BHP, BP, Brown & Root, Chevron, Civil Aviation Authority, Coflexip Stena, Conoco, Defence Evaluation and Research Agency (DERA), EC (DGTREN), First Group, Halliburton, Health & Safety Executive, KBR, Kerr McGee, Morgan Stanley, National Power, NHS, Novartis, Powergen, Royal College of Surgeons, Salamis SGB, Schlumberger, SCPMDE, Shell, Talisman, Texaco, Total, Transocean,, UBS Warburg & UK Nuclear Imc.

www.spsrn.ac.uk

Human Factors “Human factors refer to environmental,

organisational and job factors, and humanand individual characteristics which influence behaviour at work in a way whichcan affect health and safety.”

Health and Safety Executive (1999) Reducing Error and Influencing Behaviour www.hse.gov.uk/humanfactors

Human variability: Two aspects (Reason, 2000)

Human as

hazard

• Slips • Lapses • Mistakes • Violations

Human as

hero

• Adjustments • Compensations

• Recoveries • Improvisations

Safe and Efficient Performance �Individual actions

Latent Conditions

Organisational /Professional

Culture

Professional Behaviour

Technical & Non-Tech.

Skills

Job Performance

A B c

ABC

• A – antecedents eg organisational culture

– Norms of behaviour

• B – behaviour

• C – consequences – reinforcement – Rewards or punishments for particular

behaviours by supervisors, peers etc, buildsculture

Organisational Safety Accident

Causation

Technical

Factors

Human Factors

= Culture/

Manager Behaviour

+ Worker

Behaviour

The complexity of hospital cultures

a) ‘A confusion of languages’

b)Who are the leaders? nominal leaders e.g. Management but powerful informal leaders e.g. Consultants

Safety culture and behaviour

• Worksites with more positive safety culture show lower accident rates

• Workers who perceive their supervisors/ managers to be more committed to safety engage in more safety-related behaviours and fewer risk taking behaviours

• Motivational mechanism linking culture to behaviour – expectations/ rewards linked to behaviour of managers/ supervisors (Zohar, 2002)

( Landy & Conte 2006)

Safety culture questionnaires

Safety Culture Dimensions • Prioritisation of Safety

(production vs. safety)

• Management commitment to safety

Safety systems, training, communication,resources, incident reporting systems,feedback, accident analysis, teamwork,organisational support etc etc

Key worker safety behaviours

Speaking up about safety

Reporting incidents

Participation in safety activities

Rule compliance/ Risk taking

Leadership Style for Safety?

Transformational leadership (Bass) is the strongest predictor of safety in industry (Flin & Yule, 2004, Quality & Safety in Healthcare)

How do Senior Managers foster an unsafe culture?

• Sending the wrong signals by their: – language – behaviour – priorities – time allocation

• Upward appraisal of senior managers’ safety leadership (e.g. healthcare CEOs)

Changing the culture • Clarify priorities • Provide safety resources (inc. time) • Reward appropriate behaviours

• National initiatives (Government driven) • Licensing and revalidation • Patient safety education for healthcare students

• Training safer behaviours (non-technical skills)

Tenerife (1977)

Two Boeing 747s crashed into each other on the runway. 583 people killed.

Causes: conflict resolution, assertiveness, communication, situation awareness, stress – non-technical skills

Human Performance Limitations Training

• Understanding of physiological and psychological factors influencing task performance –eg stress, fatigue, work conditions

• Pilots trained at ab-initio stage

• Pilots have to pass an exam in this

• No evidence of this type of training

in Medical Schools

Pilots’ Non-Technical Skills • Term non-technical skills first used in

European civil aviation.

• ‘Cognitive and social skills of flight crew members in the cockpit, notdirectly related to aircraft control, system management, and standardoperating procedures’.

• NOTECHS – is a taxonomy and behaviour rating system for pilots’non-technical skills developed inEurope

Flin et al (2003) Development of the NOTECHS system for assessing pilots’ CRM skills. Human Factors and Aerospace Safety, 3, 95-117.

Generic Non-Technical Skills

• Leadership • Team Work / workload management • Communication • Situation Awareness • Decision Making • Personal Limitations – managing

stress and fatigue

Clinical Human Factors Group www.chfg.org

Non-Technical skills, error and adverse events

Poor Non-Technical Skills

Good Non-Technical Skills

Error Unsafe

behaviours

Safer behaviours

Avoid/ Capture Error

Adverse event

Observation, rating and feedback using behavioural rating system

Train and assess using

ANTS/ NOTSS etc

Identify Non-Technical Skills

Increased chance

Decreased chance

Anaesthetists’, Surgeons’ and Scrub Nurses’ Non-Technical Skills

University of Aberdeen, NHS Education Scotland,

Royal College of Surgeons of Edinburgh

Anaesthetists’ Non-Technical Skills

ANTS

Task Management

Team Working

Situation Awareness

Decision Making

Planning & preparing

Prioritising

Providing & maintaining standards

Identifying & utilising resources

Category

Element

Behaviour

Checks equipment, prepares drugs for the case

Non-technical skills taxonomies

Surgeons: www.abdn.ac.uk/iprc/notss/ Anaesthetists: www.abdn.ac.uk/iprc/ants/ Nurses: email: l.mitchell@abdn.ac.uk

Project sponsors: Royal College of Surgeons of Edinburgh (RCSEd)

NHS Education for Scotland (NES)

Patient Safety Education • Medical Schools (eg Aberdeen)

– Year 5 module on patient safety – Year 1 survey of knowledge/attitudes to patient safety

• WHO patient safety curriculum: medical students (for 2008)

• Canada: Patient Safety Competencies (for 2008)

• Australia: Patient Safety Education Framework (2005) – www.patientsafety.org.au

• MSc Patient Safety (Imperial; Aberdeen) – Clinicians and healthcare managers

Further information

• r.flin@abdn.ac.uk • www.abdn.ac.uk/iprc

lists of projects and papers and reports

Scottish Patient Safety Research Network www.spsrn.ac.uk