You don’t come to work for things to go wrong

You don’t come to work for things to go wrong. And yet, they do. When things go wrong sometimes the impact is significant and other times minor. It may affect you, your colleagues, patients and their families.

Human Factors can help us understand why things go wrong. And it can help generate ideas to prevent something similar going wrong in the future. Quality Improvement tools and techniques help us to test and implement those ideas in our quest for improvement. We think a day where we learn about combining the two is a day well spent.

Someone recently told me about a theatre where there are four different checklists. Now, we know from human factors that reliance on human memory and unstructured communication can contribute to errors. And that checklists can be helpful in preventing these sorts of errors. Each of these checklists have been developed with good intentions to prevent harm.

However, staff in this theatre are now confused and frustrated so they don’t use any of the four checklists. This means they are still relying on human memory and unstructured communication which can contribute to errors.

Using quality improvement techniques in this situation could have involved staff so that they tried out checklists to make them work in their setting and measured the impact of the checklist in their theatre. This would have made it much more likely that the checklist would be used, and future errors avoided.

A second example is an incident where harm did occur to a patient because a clinical area had not been properly cleaned between patients. Initially senior leaders blamed the frontline clinical staff for not following the policy which said that the clinical area needed to be cleaned between patients. Human factors analysis helped the senior leaders to understand that it was physically impossible for that member of staff to clean the area within the time allowed between patients and therefore identify learning rather than blame. In this example, quality improvement tools and techniques could then be applied to try out different ways to make the clinical space safe between patients.

Both these examples demonstrate how combining human factors understanding with quality improvement tools and techniques could really help you to prevent things going wrong in your day.