Improvement of non-technical skills in theatre must be made a priority, according to high profile speakers at this year’s Association for Perioperative Practice (AfPP) Congress. Seventy per cent of disasters are caused by a failure in communication – yet, in the clinical setting, there is often poor awareness of the role of “human factors” in causing surgical harm.
Martin Bromiley, chair of the Clinical Human Factors Group, who tragically lost his wife Elaine, in 2005, following routine surgery, commented: “In the NHS there is a tension – people are unsure whether productivity or safety is the top priority. Although there is increasing recognition of clinical human factors, some people are still unsure about what it means. The role of human factors is an area that the vast majority of healthcare professionals, policy makers, managers and politicians are still unaware of.”
Some of the common human factors that can increase risk include pressures from workload, distractions, teamwork and process design.
Dr Jane Carthey, a human factors specialist, was the first speaker at the well-attended session on “Error, wisdom and foresight”, during the AfPP Congress. She introduced the audience to the concept of “foresight” as a valuable tool in the armoury required by healthcare professionals in order to counter balance the likelihood of a patient safety incident occurring.
By developing skills in foresight and “error wisdom”, Dr Carthey said that healthcare staff are more likely to recognise error-prone situations and thus intervene. She provided an insight into strategies aimed at anticipating and mitigating risks caused by human factors during surgery.
Mark Emerton, consultant orthopaedic surgeon, Leeds Teaching Hospitals, and clinical lead, NHS Institute for Innovation and Improvement, said that an understanding of human factors could provide the next breakthrough in advancing surgical outcomes. He pointed out that cultural issues in relation to approaches to human factors need to be addressed – teamwork is essential, along with situational awareness, and the ability to communicate with colleagues.
“Everyone in the room needs to feel able to speak up if they see something going wrong. A feature of some of the worst incidents is that, in most cases, someone knew what was going on and wanted to say something, but felt unable to do so,” he commented.
“Studies also show that units that have the highest measure of teamwork have the lowest rates of septicaemia and bacteraemia,” he pointed out.
These and other themes explored at AfPP will be examined in detail in the printed edition of The Clinical Services Journal, published in November.
