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Human Factors - Developing Bespoke Solutions


Human Factors and Ergonomics is the study of how humans behave physically and psychologically in relation to particular environments, products, or services.  The Human Factor Exchange is a pioneering programme by Health Education England working across the East Midlands. The aim of the exchange is to apply and promote Human Factors in Healthcare and to improve the quality of care for the patients throughout the East Midlands. The Human Factors Exchange is made up of a number of individuals with both academic and clinical backgrounds from a variety of institutions across the East Midlands.

One of the Human Factors' exchange work streams is working with NHS staff to develop bespoke solutions for improving patients safety and quality thought the lens of Human Factors.

There are currently 6 projects running in the East Midlands

Improving recognition on and management of acute type 2 respiratory failure

Based in Derby, the aim of the project is to improve the recognition and management of acute type 2 respiratory failure as a medical emergency, including the safe administration of oxygen.  Using human factors methods to understand why errors happen and design systems to improve patient outcomes. An intervention of a simulated training package for key staff identified will be introduced, which includes training of additional staff groups to take capillary blood gases. Awareness of type 2 respiratory failure will also be raised through a campaign as well as respiratory workshops which Medical Assessment Unit (MAU) staff and Core Medical Trainee Doctors will be encouraged to attend.

Improving Handovers in the Community

The aim of this project is to adopt a human factors and ergonomics (HFE) approach to the analysis of reported incidents where patient safely is compromised as a result of handover or the discharge process, rather than delivering an educational intervention, the main focus of this study is to analyse the discharge process from a human factors perspective. By applying human factors and ergonomics principles and methods to the analysis of the discharge process, key areas that may require attention will be identified and the basis for a scientifically sound intervention will be developed. To ensure the discharge process is understood as comprehensively as possible and holistically, various groups of staff members involved in the different phases in the discharge process will be included and both quantitative and qualitative data will be captured. By applying HFE principles already at the initial investigation of the process prior to developing interventions, it can be ensured that the human aspect of the discharge process has been considered throughout the analysis and the intervention development.

Improving safety by electronically acknowledging results

Test results are an important part of evaluating a patient’s clinical condition and should be considered with other clinical information. The main area where problems frequently occur are with critical tests results and for patients moving across healthcare settings. There is widespread evidence of the negative impact on patients when important test results are not actioned. This project seeks to work with clinicians to understand the HF element of acknowledging results and use this understanding to adapt the current IT system to support results acknowledgment in the future. The success of the IT intervention will be measured by clearing the backlog of unacknowledged items on the system and monitoring the new numbers of unacknowledged items as well as supported by qualitative data gathered through interviews with clinicians interacting with the system.

TRUTHFUL – Transforming Root cause analysis using the Lens of Human Factor to better understand and underpin lesson for learning

The main purposes of conducting error investigation, such as Root Cause Analysis (RCA), are to identify the contributory factors following events and to learn from the event to inform quality improvement initiatives and minimise future risk of similar events. Transforming Root cause analysis using the lens of Human Factors to better Understand and Underpin Lessons for Learning (TRUTHFUL) aims to use Human Factors theory to inform and improve RCA in a clinical context. It does not aim to provide an incremental improvement to RCA but attempts to approach error investigation prior to a Serious Untoward Incident (SUI). The TRUTHFUL project will develop a framework that will facilitate professional development in doctors in situ and attempt to actively reduce the contributing factors that lead to SUIs. This resulting framework will contribute to RCA toolkits. Indicative analysis suggests that TRUTHFUL can strengthen education around Human Factors in situ and that there would be a potential that the intervention could contribute to cost savings by reducing SUIs and improving patient safety and RCAs.

Mobilizing human factors knowledge to maximise safety huddle impact: Protecting Patients & Optimizing Organisations

Communication in complex, high-pressured and safety critical environments such as in a healthcare setting is challenging. Ineffective communication among health care professionals is one of the leading contributing causes of medical errors and patient harm. The aims of this project are to improve situational awareness and communication in teams within a healthcare setting. This will be achieved through short multi-professional meetings which include all staff on the ward from housekeeper to the consultant in charge. These Safety huddles will improve situational awareness and should reduce the prevalence of SUI’s based on the associated literature, they should encourage the raising of concerns, by creating an environment that is psychologically safe by breaking down the power dynamics associated with difference professional groups and create a more supportive culture and environment that improves team and organisational learning.

Implementing Human Factors approach for planned and unplanned extubation in critically ill adult patients

The aim is to improve patient safety and staff well-being in relation to the management of unplanned (and planned) extubation of adult patients in the critical care setting. This will be achieved using a simulation-based mastery learning (SBML) programme to prepare and maintain the skills of key clinical staff in airway rescue management. A Human Factors analysis of the environment, work, task, and skill mix will inform any associated systems redesign alongside the development of the mastery learning programme. This will include a modified sentinel event analysis, review of processes associated with management of planned or unplanned extubation, and clarification of training needs related to individual technical and non-technical skills and critical team working skills and behaviours

This Page was last updated on: 20 March 2017

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