New guidance has been published to enable clinicians to design and maintain safe systems that will reduce the risk and potential impact of human error.
The guidance has been by produced by a working party of the Difficult Airway Society and the Association of Anaesthetists, and is supported by the Royal College of Anaesthetists and other national organisations. It includes 12 recommendations:
1. Design of medical equipment should include input from human factors experts at an early stage (where it is possible to still change the design if necessary – this is not currently always the case). The medical equipment procurement process should include human factors assessments.
2. Design of drug ampoules and packaging should incorporate human factors principles to optimise readability and reduce the risk of mis-selection: anaesthetists, pharmacists and procurement departments should ensure that these principles are prioritised during their purchasing processes. Improvements that could make a difference include making the drug name more prominent than the manufacturer’s name and logo, prioritise generic drug names over trade names and consider standardised use of colour, while being mindful of the impact of colour blindness.
3. Design of safe working environments should incorporate human factors principles. Regular reviews should be carried out to ensure that safety has not been compromised – this can cover anything from the design of the whole hospital to operating theatre design, and how moveable equipment is used in each operation.
4. Operating theatre list planning and scheduling should include additional time allocated or complex cases and for high turnover lists to enable adequate preparation and reduce time pressures on staff.
5. Cognitive aids, including algorithms and checklists, should be designed and tested using human factors principles to ensure usability and efficacy.
6. Non-technical skills can be learned and developed, and should be practised during everyday work to ensure that staff become skilled in their use and are able to use them effectively. (Many examples exist and include all staff wearing a name badge and using first names of team members, and situational awareness – being aware of what has happened in a situation, what is currently happening, and what could happen in the coming moments.)
7. Investigation of critical incidents and adverse events should be performed by teams that include members with human factors training using a human factors investigative tool. Lessons identified should be shared. An example of this is: a new patient safety incident response framework (PSIRF), based on human factors principles, is replacing the existing root cause analysis investigation tools that are currently in use in the UK healthcare system. (Hospitals have been given until Autumn 2023 to implement this.)
8. Morbidity and mortality meetings should be part of the regular work of all anaesthetic departments and should also include learning from cases that go well. Time within job plans should be allocated to enable staff to prepare for and attend these meetings.
9. Human factors education and training should be provided at an appropriate level for all anaesthetists and all members of operating theatre teams. It should include the role of good design in healthcare, an appreciation of a systems perspective, the importance of non-technical skills and strategies to improve these.
10. Non-technical skills training and interprofessional simulation training: Teams that work together should train together. Non-technical skills should be learned during classroom and in-theatre teaching, woven into all anaesthetic workshops and courses and rehearsed during regular interprofessional simulation training. Time and resources should be allocated to allow for this.
11. Staff well-being should be optimised by hospitals and anaesthetic departments by implementing organisational strategies.
12. Each anaesthetic department should have a human factors lead with an appropriate level of training. Every hospital should have patient safety leads with appropriate training and qualifications; in England, this is already included in Health Education England recommendations.
The full guidance is published in the journal Anaesthesia.
