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Here we share some thoughts, insights and ideas related to Human Factors Training

Reacting to tragedy - the aviation experience

It is, of course, inappropriate to speculate on the possible cause of the tragic Ethiopian Airlines crash. However, the reaction offers lessons I believe.

The authorities in Ethiopia and China have grounded the same model virtually instantly until root causes are understood and appropriate measures have been taken.

It may be significant that the aircraft is the same new model as crashed in Indonesia in late 2018, or it may not. Risk management is the name of the game.

One of the contributing factors in Indonesia was the new safety feature built into the aircraft software. The concept was to improve the way the aircraft responds to an unwanted state and is supposed to be an aid.

It is called the Manoeuvring Characteristics Augmentation System (MCAS). It is designed to prevent the aircraft from falling out of the sky in an aerodynamic stall.

However, it appears that the manufacturer, Boeing, did not incorporate the knowledge of the system in its training to crews. Many qualified crews around the world have stated that they nothing about the system's existence.

To compound the problem, it appears that the Indonesian aircraft may have been despatched with a known technical problem which the ground engineers may not have been able to reproduce on the ground.

In other words, the safety system responded correctly, but the suspicion is that it was being fed erroneous data from a faulty sensor. In this case the AoA (angle of attack) sensor – which detects the airflow over the wings.

Some of you may be aware that a cost saving feature is that this latest model of Boeing 737 is deemed to require only 'differences' training if a crew is qualified on the earlier model. They do not do a full technical knowledge course just learn and are assessed on the differences.

It seems the new safety feature was not included. Human error by the manufacturer? The result in a non-technical sense is a loss of situation awareness – how and why the aircraft is reacting.

Those of you who remember the tragic Kegworth crash in January 1989 which started with the crew identifying the wrong engine in an unclear flight situation and ultimately crashing across the M1 motorway in England's East Midlands.

Of the 126 people aboard, 47 died, and 74 sustained serious injuries.

Implicated was the pilots not being aware that the right engine supplied the air conditioning to the flight deck as opposed to the left engine in previous models.

The smell of burning was a small misleading clue. They had only completed a very brief 'differences' course.

Airbus have also suffered accidents in the past because the aircraft was so advanced and complicated that crew struggled to understand how the plane was reacting.

History can repeat, but we learn the lessons the hard way.

I flew six different airliners from four different manufacturers in my career. Comprehending what was going on was sometimes tricky and fundamentally down to how well the crew knew the aircraft. In other words, training.

In other professions such as healthcare, we all involve people trying to comprehend what is going on.

Healthcare professionals face a much more difficult job because no two patients are the same even more so than with aircraft. Knowledge and understanding are crucial, especially in how any one of us can get it wrong and right.

Human factors has been mandatory training in aviation since 1995, and even that can't prevent everything. But it sure helps.

I've presented training packages to several NHS Boards and senior management teams. Not surprisingly cost is a feature. Some get it; some seem to struggle.

After all, finding a direct correlation between safety and training is not easy.

But precisely who initially said, "If you think training is expensive, try having an accident"? I'm not sure, but it has been attributed to many wise people over the years.

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What’s in a name?

In our everyday lives, people are typically polite to each other. At social events, we carry out personal introductions a matter of course.

So why is this behaviour not the norm in healthcare?

When working with healthcare teams that are sometimes experiencing challenges with safe team workings, we often observe a reluctance to introduce ourselves by name - especially our given first name.

When I joined my first airline employer in 1971 that was indeed the case.

The Captain was always addressed as Captain or Sir, on and off the aircraft.

I still vividly remember my first BOAC flight as a very lowly second officer under training. The Captain was a very senior manager and trainer, and he exacerbated the situation by referring to me to his chums in the bar in Manhattan as 'one of those bloody cadets still wet behind the ears'. What an excellent example to set.

It was an example I chose as a model of what not to do when I finally achieved Command 18 years later.

Furthermore, I made a point of never introducing colleagues as 'my First Officer' or 'My Cabin Crew'. These are professional people in their own right and deserve all the respect associated with it.

This is an important issue because failure to use given names in the workplace can create a significant barrier to people speaking up when they have doubts about safety.

Why would any professional want to place an additional block to open communication, especially if someone's' life could be at stake?

I met one senior clinician in the last few months who looked with abject horror when I suggested they make a point of introducing themselves by first name at a pre-surgery huddle! "I really don't think I could do that", she said! Why on earth not?!

The unit in question has an appalling staff attitude survey result, a string of 'Never-Events' and 'near-misses', a high sickness rate and high staff turnover. Go figure!

The excellent Rob Hackett in Australia had the astonishingly simple idea a while back of putting name and job title on his theatre hat. This has become known as 'the theatre cap challenge'. Odd isn't it that it should even be regarded as a 'challenge'!

It's quite amusing to hear all the excuses why people can't adopt this simple practice of the theatre cap challenge in their own unit.

Infection risk? Well, there is a chap out there making them integral in theatre caps. You could invest in a few to get you through the week if you like your own personalised hat.

Power is granted, respect is earned.

We must not forget either that using titles can help in difficult situations.

As an airline captain, there were many occasions where a colleague referring to me as Captain Dale was useful to re-establish appropriate hierarchy in front of passengers or an engineer.

The other week I was delivering a talk in Bath, to a room of around 100 healthcare professionals, ranging from medical students to retired senior consultants.

When I reached the end of my talk, I asked how people in the room felt about using first names? I explained that when you have to think about titles and ranks, you are creating an additional barrier to someone helping you out when you need them the most.

I don't mind if you introduce yourself as Professor John Smith, but I prefer if you call me Professor Smith. This might not be as beneficial as working on a first names basis, but it sure beats the all too common introduction, "We all know each other don't we?" which equates to "You all know me, don't you? .. and you don't matter".

Do get in touch to discuss how our human factors training for critical teams can help you maintain and enhance safety.

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The familiar tale of high staff turnover



I've been chatting to various clients and a regular subject that we return to is high staff turnover. 

Many organisations do not perform exit surveys and so understanding why people leave is a problem to start with. Perhaps they don't really want to know. It's easier to blame the NHS and pressure of work, targets etc.



For example, Atrainability worked closely with a world famous specialist hospital a little while ago which was suffering high turnover of junior nurses in a particular department.


The view from the top was: 

"The nurses come here to get our good name on their CV's and then move on."


However, anecdotally people were leaving because it was not a great place to work.

Team-working was verbally espoused but reality was somewhat different. Work as imagined was quite different to work as done depending on your level in the hierarchy. 

One nurse told us she had worked her entire shift without any offers of help, breaks or support while the band 6 and 7 nurses had a nice relaxing time. You can imagine the atmosphere when we presented our findings. 


This is by no means unique as many of you will know. 

This very week I've listened to my best friend's wife explaining that she is burned out and leaving the profession the she loves. The reasons? She is a specialist sister in intensive care who is often told to work in other departments. She has been sent to A & E, theatres, wards and even the other sites in her trust which is 20 miles away. 

She has simply had enough. 

What a tragedy which is personal, institutional and cultural for her and us all. 


In London there are 8000 nursing vacancies and huge doctor numbers too, so making your job one that people want to come to must be worth working on? 

Staff retention rather than repeated training costs is a very worthwhile investment, and turning from a Blame Culture to a Just Culture is a crucial start. 

A worthwhile part of team-working is delving in to emotional intelligence and a fundamental concept within that is of course self-awareness. 


Get in touch and discuss with us how we could help your teams, including the senior level of course. 


Trevor Dale, Human Factors Specialist

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Human Factors & Patient Safety Updates (Oct18)

In this edition:
  • Civility Saves Lives
  • Group GP appointments - a breeding ground for error?
  • Waverley BIG Awards Finalist
  • Human Factors in Practice
  • Free conference this November

Civility Saves Lives

Civility when dealing with colleagues and patients may seem like stating the obvious, but sometimes what should happen in theory isn't what happens in practice. 

Civility Saves Lives is the self-funded, collaborative project led by Dr Chris Turner, a Consultant in Emergency Medicine. 

Why does civility matter? Uncivil behaviour not only greatly impacts the reciepent, but it is also proven to have an extended impact beyond the recipent. At Atrainability, we refer to this as 'Mood Contagion'. 

Many professionals have been on the receiving end of rudeness, belittling and bullying. Most are told or feel like 'that's just the way it is'; but if the NHS truly wants a Culture Change behaviours and attitudes at all levels need to adjust. The project aims to raise awareness of what can be done, whilst sharing stories from other professionals as well as relevant, evidence based academic papers.

Atrainability's Trevor Dale has recently been speaking about the importance of civility at Patient Safety Collaborative for Kent, Surrey & Sussex. If you'd like to find out more about how Human Factors training and Civility fit hand in hand, request more information by emailing team@atrainability.co.uk. 

We also highly reccomend taking some time to look at Christine Porath's work. Her book 'Mastering Civility - A Manifesto for the Workplace' has recieved excellent reviews in The New York Times as well as from high profile authors and leaders.



​Group GP appointments - a breeding ground for error?

There has been a recent report about the NHS considering group GP appointments as an option to help alleviate the waiting time for patients and in an attempt to manage the growing shortage of GPs.

 Although further details on this are needed, we at Atrainability believe that this could very well be a potential breeding ground for Human Factors error, our main concerns from a Human Factors perspective include:


 • BEHAVIOUR & COMMUNICATION: The patient relationship with their GP, being confident to raise real concerns. How does the GP manage a room with some extraverted (verbose) people and some introverted (more private & more inwardly driven)?


 • SITUATION AWARENESS: Potential error when adding correct patient notes to correct individual files - how will this be managed from a group sessions?


 • CONFIRMATION BIAS: A group may have similar symptoms, but will this lead to the same path of care? The correct diagnosis? Could things be missed? 


Are you a GP? 

We'd appreciate your thoughts on the subject. Email us in confidence: team@atrainability.co.uk.



​Waverley BIG Awards Finalist


You may know that we've been training health and social care teams across the UK for the last 16 years, however you may not realise that we're classified as a small business. Which is why we are delighted to have been selected as a finalist for Waverley's B.I.G Awards 2018 in the category of 'Customer Delight'. We'll keep you updated on the results which will be announced on 19 October.


​Human Factors in Practice


We were recently copied in on communications from a client to another organisation who were enquirying about our services. We have been granted permission to share this with you: 

Sent 19 September 2018 
Subject: Human Factors in practice 

Hi __________ I'm sorry to have taken so long to reply. We are six weeks in to our annual CQC inspection activity – what is perverse is I am responding to you on today of all days as today is the first day of the actual well-led inspection! 

I have to say, embracing Human Factors was the start of our journey and absolutely the right place to start. There is no other way to, in NHS terms, make the shift from compliance to continuous improvement, or it is likely you would regress back to a compliance focus. Embracing Human Factors tackles capability, by that we mean confidence, competence and capacity. Most other approaches cannot do this and that means you lose staff engagement from the outset. 

I am glad to hear that you are looking to improve the safety culture in your organisation. That shows a lot of insight on your part – a lot of organisations tackle just "culture", which then takes things down an OD direction. Also, culture is a funny term, we do need to break it down into its component parts and Human Factors tackles component parts that other approaches cannot. 

As a direct consequence of our Human Factors work, we have now moved away from audit to improvement and now each team is worked with, as an MDT, to look at their safety performance and we also undertake a patient safety culture survey. This has revealed things to us that our typical assurance mechanisms have not, e.g. we would assume our incident reporting profile equals a safety positive culture, but perception of staff shows that there is still work to do. 

We have used The Health Foundation Model to help us improve how we measure and monitor safety, however having been on the journey, you can't just implement that, Human Factors needs to be grounded in all you do first. I have seen many organisations where Human Factors becomes something that is led by OD and becomes associated with "communication" – Human Factors is much more than that. 

Taking a look at your organisation, it looks like not only do you have a similar profile to us but your CQC ratings are almost identical. We are rated Outstanding for Caring which we put down to, in part, our work in relation to Human Factors. The Safe domain is always a difficult one to shift – let's hope this inspection changes that! Feel free to come and see us or we will come and see you, if you have any questions. We are also open to partnering on things. However I would revisit offers from Human Factors providers first as that really is the foundation. 

Of course my experience is of using Atrainability and there are many reasons for that, aforementioned, in-house approaches risk this being seen as a communication thing, whilst other companies do not tap into the SME that experts in the airline industry have. We have used Atrainability to train what we call "culture carriers" or then have spread and sustained this approach in what has then developed into our patient safety improvement (safety management system) work. 

Atrainability also did two bespoke sessions with our Board, as that demonstrated to our staff the commitment of the Board. So I would suggest you need a programme of works that tackles all levels of the organisation for this to work – we didn't know it at the time, but we used the dosing model which you are probably familiar with. That will help you present any proposals to your Board as this is an evidence based way of building capability in a sustainable way. 

Good luck on your Human Factors journey! 

David Wood, 
Associate Director of Safe Services Cheshire & Wirral Partnership NHS FT


​Reminder! Free Future of Healthcare Conference this November


​Atrainability are proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at The Future of Healthcare Conference, which is free to attend event on 6 November in Exeter. 

The conference brings you speakers from a wide spectrum of specialties. The aim is to inspire & teach NHS staff from all departments, as well as patients, on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance. Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter.

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The Tragic Cost of Avoidable Harm

As I'm writing this, it's only Wednesday, but we have already been made aware of four unrelated never-events at seperate healthcare providers. The unfortunate truth about committing to a Human Factors training programme is that many organisations put it off, until they receive a wake-up call in the form of a never-event, a near miss, bad press or from the CQC. Someone gets told this needs to be addressed, and that's when our phone starts ringing.



The first tragedy of so many harm related incidents is that on reflection they could have been avoided. 

That's one of the reasons this headline in the National Health Executive: "NHS pays out record £20m compensation for brain-injured teenager" caught our attention, but also because it's potentially the largest compensation pay-out in NHS history. 


The second tragedy of avoidable harm is that the suffering of all those involved doesn't end with the error.

The judgement suggests the error was avoidable. Hence Human Factors behaviours will likely have been suboptimal. In this particular case, not only did this nameless young lady have her full enjoyment of life tragically taken from her, but also her parents and entire family. 

We can only imagine the emotional toll that they have endured for the last eighteen years to have this life changing error acknowledged and receive some form of compensation towards her ongoing care. 

Let's also recognise the effect on the healthcare team involved. It's likely that disciplinary action would have been taken, but they have almost certainly been haunted by the knowledge that they could have avoided or trapped the error. 


The third tragedy of avoidable harm, is that it sadly continues to occur. 

There will always be mistakes in healthcare, but embracing a Human Factors mindset can enable your team to be confident in modifying the actions and behaviours that affect safety. 

Atrainability have over 16 years' experience in training and supporting healthcare teams on their individual journeys to truly learn, become more effective and begin to change behaviours for the better. If your teams are performing highly now, consider helping them to stay 'consciously competent' and avoid the trap of complacency.


Please get in touch and let's see how we can help your teams.


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Human Factors Courses for Foundation Doctors

The General Medical Council has reflected the importance of recognising Human Factors in the development of generic professional capabilities for post graduate medical curricula. 

The context for this is the GMC's core guidance for all doctors, good medical practice, which sets out what is expected of doctors including communication, partnership and working with patients. (National Quality Board Human Factors Concordat 2013) 

Many Deaneries have incorporated Atrainability's Human Factors modules in their curriculum, since 2012. The list is growing year by year and the repeat bookings speak for themselves. 


Atrainability are now taking bookings for Foundation Doctors Human Factors Training for the next academic year

Human Factors is strongly recommended to become a mandatory part of Medical Education and our courses match the Medical Leadership Competency Framework.

Focus points include: 

• how and why errors are made and practical tools to avoid and trap them 

• safe decision making during a stressful day 

• situation awareness - recognising the signs that things are going wrong and dealing with that situation 

• effective escalation - overcoming the barriers to open communication and shared understanding in a high workload environment 

• dealing with difficult people including, sadly, colleagues 


We have over 6 years' experience in delivering training aimed at the next generation of healthcare professionals in a manner that is tailored to their educational needs. 

The Human Factors behaviours related to safety are crucial both for the patient and also the professional confidence within the Doctor while they are in the most high risk part of their education. 

If you have already finalised training for 2018/2019, we'd be happy to discuss your training programme for the next academic year.

Some sample feedback from recent participants: 


"Outstanding course, incredibly useful" 


"This should be mandatory! Very interesting to learn how other industries such as aviation can apply to medicine" 


"Leadership & management is crucial but often overlooked in medical training. Clear, practical advice that I can start putting into practice now." 


"Useful to receive formal teaching in things that it seems we are expected to already be aware of e.g. challenging authority. Good presentation, kept engaged throughout." 


"Important concepts to reflect on, extremely useful to be exposed to this early on in our career" 


We would be happy to discuss your individual needs at your convenience. Please contact us here.

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Unprofessional behaviour in the workplace

The recent press reports of a 'toxic' atmosphere at St George's hospital in South London are distressing to say the least but unfortunately by no means isolated. 

Relations between colleagues in any profession can break down or face difficulties at times. However, healthcare professionals are often a keen focus for criticism in the media and so it's important not only to understand how to prevent unprofessional behaviour in the first place but also how to manage high-performing professionals into cooperative team-working when under pressure. 

In over 16 years of working with health and social care professionals across a wide spectrum of disciplines we have encountered far too many instances of uncivil behaviour sometimes directed at us and certainly at fellow team members. 

It is worthwhile mentioning that this applies at all levels and specialties and not as some apparently think, doctors alone. Currently we are working with organisations where problems exist within nursing bands. When trying to help teams understand the effects of uncivil behaviour we ask the following:


WHAT DOES IT MEAN TO HUMAN?      VS       WHAT DOES IT MEAN TO BE PROFESSIONAL?


Here are sample answers, by no means exclusive:

Maintaining high standards of professional behaviour is a major challenge in any high-pressure working environment. We will sometimes fail to get it right because we can not avoid being human.


MAKING EXCUSES...

One clinician sought to excuse his colleagues inappropriate behaviour by saying the surgery (neuro) he performed was very complex, high risk and stressful and that stress had to be vented somewhere; and so in this way he justified the bullying his colleague dished out to theatre teams! 

Thankfully, this clinician always behaved impeccably with patients and relatives but there is no excuse for undue criticism or abuse of colleagues.

Why does he think it is an appropriate way to behave?

Does he realise the impact he has on staff feeling that they can speak up in the unlikely (we hope) event of some avoidable error?

How will the added stress of working with someone difficult effect the performance and focus of the rest of the team?

If you look again at the 'What makes a professional' image; what makes him believe that he is practicing in a 'professional' manner?

More importantly, how can he be helped to gain self awareness? Certainly not by people making excuses for his behaviour and certainly not by team members keeping their heads down.

MANAGING HUMANS

Everyone has what we refer to as their personal 'stress bucket'. 

So in dealing with 'difficult' people, especially as a manager or team leader it can be helpful to consider why they behave this way. 

Could they be ill or facing huge personal stress, having a personal crisis? Could they lack insight or skill? Could they believe it to be acceptable because that's what they experienced? Could it be my fault? Winding them up? Could they just be plain awkward? 

The first step is to recognise the 'human' elements, treat everyone as an equal with dignity and compassion and by that try to encourage the 'difficult' people into the same behaviour.​

// View our Walking the Tightrope Course here. //


This can be easier said than done, especially if you're not in a management position but one of those perhaps at the blunt end of the behaviour.

In those circumstances the simplest advice would be to reframe your response to this behaviour. For inappropriate behaviour such as bullying or intimidation, it is common for individuals to be singled out as the 'victim'. 

Therefore sticking together as a team is crucial. It is certain that you are not the only one who has noticed or feel uncomfortable with the behaviour. As a collective it's important to not allow yourselves to become victims but to stand together and respond professionally, politely but firmly. 

As a common example if someone refuses to follow a procedure (such a safety checklist, briefing etc) declaring it a waste of time or they know better etc. Together the team needs to take the stance "I'm afraid we will not be going forward with this until this is done." 

Regardless of your faith in reporting systems there should be one that enables you to get support from your management, but any reporting with regards to inappropriate behaviour must be evidence based.


REPEATED UNCIVIL BEHAVIOUR

The NHS is notorious for having a culture where professionals are treated effectively like children. If you treat people in such a manner don't be surprised if you get a child-like response.

However if you treat people in an adult manner, as equals, with respect and understanding it is more difficult for them to maintain an unprofessional behaviour pattern.

At the same time it should be made clear that continued unprofessional behaviour and bullying cannot and will not be tolerated. This comes under the heading of duty of care to the rest of the staff. A fundamental management responsibility.


However, we know of a current situation where after evidence of repeated uncivil behaviour, a formal interview was undertaken with an official warning on file.

The staff member has returned to work, but the manager suspects no behaviour change has taken place and is not getting any further evidence from other staff because presumably they feel that nothing has been done and therefore why waste time making reports?

A conundrum indeed because managers cannot publish confidential personal reports for obvious reasons. Here we believe having a cadre of Human Factors Champions in the workplace could help.

They could be the interface in the workplace and offer advice and support to both staff and management.

So we return to a Just Culture - one where genuine human error is treated with understanding but equally failure to follow standard procedure habitually and inappropriate behaviour towards others is simply not on.


Make an enquiry about creating Human Factor Champions in your team here.

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Human Factors & Patient Safety Updates (Aug 2018)

Free conference for NHS staff this November

We're proud to be speaking alongside Roy Lilley, Cara Charles-Barks (Salisbury NHS), Dr Mohammad Al-Ubaydli, Mark Coooke (NHS England SW) & Dr Felix Jackson at this free to attend event on 6 November in Exeter. 

The future is uncertain. With the dawn of technology, will healthcare staff be usurped by advanced apps & artificial intelligence? What leadership strategies are in place to help NHS staff cope with the Salisbury Novichok incidents? How will joint working & mergers affect staff? 

This event explores Collaborative Networking - The Future Of Healthcare. This free conference brings you speakers from a wide spectrum of specialties. We aim to inspire & teach NHS staff from all departments as well as patients on how to adapt to systems change in a way that brings about efficiency & value. Addressing two of the fundamental themes of Future Focused Finance.

Find out more here & don't forget to follow the event organisers @nhsFFF on Twitter

Fixing a System Under Pressure

Everyone seems to say now that they have a 'Learning Culture' - but what is your SOURCE of Learning? 

The British Medical Association has recently shared some of the footage from The Future Vision for the NHS workshop ran last month. On the day around 50 members from across different parts of the medical profession came together to contribute ideas, experiences and examples to help inform the BMA's work to press for change in the NHS.

Watch a selection of videos from the event here, including 'Fixing a System Under Pressure' a short presentation from Atrainability.


Excellent Feedback from Serious Hazards of Transfusion Conference


​We were recently sent the official feedback from the SHOT blood service conference we spoke at in July. 

This year saw record numbers of delegates, which could be partly attributable to having more international delegates from the IHN meeting. 

There were 270 online submissions for the evaluation survey, which was a response rate of 85.7% (the evaluation survey was sent to 315 individuals, excluding exhibitors). 

Trevor Dale spoke at the conference about Walking the Tightrope.

The feedback on the conference was exceptionally positive, and we were very happy to receive top scores on most informative and best performance of the speakers.


Who's tweeting Human Factors...

One to follow: #learnnotblame is the fantastic campaign lead by Dr Cicely Cunningham launched by The Doctors Association UK, we'll definitely be following and supporting her progress as she raises important issues that's relevant to Human Factors values.

That's our round up of the updates from us for now, please get in touch and let's see how we can help your teams.

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Human Factors and Patient Safety Updates





PATIENT SAFETY TEAM OF THE YEAR

The winners of the HSJ 2018 Patient Safety Awards have been revealed. Well done to everyone who was nominated, commended or won! In particular, we'd like to congratulate the University Hospitals Coventry and Warwickshire Trust Patient safety and risk team. Their team have been awarded the Patient Safety Team of the Year. 


"Integrating Human Factors principles into our safety investigations has been a key part of the changes we have made. An understanding of these concepts is key to learning and improving as an organisation when things go wrong. We started our Human Factors journey two years ago with Atrainability and their Train the Trainers course, and this gave us the knowledge and confidence to develop a systems based investigation process that moves away from blame, towards learning and ensures that the patient is at the heart of what we do." 

- Stephen Tipper, Human Factors Programme Manager

Since instituting a raft of measures over the last year the incident reporting rate at the organisation has increased from 31 to 44 incidents per thousand bed days – in the top 25 per cent nationally. There have also been improvements in staff survey responses on feeling secure when raising concerns.

We of course can not take credit for their achievement but we are proud to have played a small part of their wider plan to make sustainable changes to patient safety with the 5 day Train the Trainer sessions we ran with them two years ago.

Read more about their changes and award here.


TRAINING WITH THE TEAM AT UHNM

Last week we ran 2x two-day Human Factors Awareness workshops for adult and children intensive care teams at UHNM. The courses were presented by our Founder, Trevor Dale and one of our new team members, Rick Craft.

During one of the two-day sessions, our trainers had the pleasure of talking with Emma Biddulph, a Play Specialist who is featured in an article in The Guardian on 70 years of the NHS. Emma told us:

"I came not knowing what to expect, but I found this course really interesting and useful. I plan to start implementing human factors learning asap in my daily practice."

Emma Biddulph, a Play Specialist
We're happy to report that 100% of the staff said they would 'Reccomend this training to a Colleague' and 100% also told us that as a result of the training it was likely or very likely that they would be able to apply the learning to their practice. Enquire about Human Factors Awareness Course

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A systems thinking approach to error

Attending the Clinical Human Factors Group Open Seminar this year was a great pleasure in many respects, interacting with old friends and new. Learning about updates and gaps in my knowledge in all aspects of Human Factors, was so very valuable.

It was evident from the conference that systems thinking is the way forward and the overriding theme of the day was about looking at the bigger picture whilst ensuring we don't lose sight of the individual in the process, especially the patient. We lose sight of the individual at our peril, but more than that, the patient's peril.

When organisations want to identify specific areas to improve or show evidence that they have indeed achieved improvements, data is crucial. But data so often can mask the fact that we are of course dealing with real people.

Whilst 'live tweeting' at the conference about this very subject, a fellow tweeter commented:

And how very true that is; you need both the data combined with the human story to understand why change is needed, why something has gone wrong or particularly well and also to convince others to become advocates, sharing the learning and helping to implement what is required. 


We completely support the idea of systems thinking. One of the talks that I listened to with interest was focussed on Root Cause Analysis. They talked about one particular study and what they found was the Root Cause often came back as: 


                                                                                   "Process Not Followed". 


Now, that sounds like an easy answer, but firstly, that doesn't give much to work with. That's almost as bad as pointing your finger at someone and saying, "That person didn't do it right." More details are needed to understand what is going on.

Taking a systems approach to the 'Root Cause' would take into account the bigger picture and begin to investigate WHY it wasn't followed. 


Is it a training issue for the individual? 

Is there something wrong with the process which means it's very difficult for front line teams to do their job and adhere to the process?

Or, could it be the person is in the wrong job? 

Perhaps it's 'the process' and not the person that is the real Root Cause and it needs revisiting. 

It certainly seems to be the case with a number of Surgical Safety Checklists, where it looks like the checklist itself is not fit for purpose. 

We are currently working with an NHS Trust where the checklist is not fit for purpose. Investigating, observing and promoting open conversations with front line individuals is a good start for any organisation that wants to understand what they can do to make improvements. 

Overall there was a strong feeling of optimism at the Clinical Human Factors Group Seminar. There are, without a doubt, more people taking an interest in Human Factors in healthcare and there is also some truly excellent and insightful work on developing solutions to changing the Culture on this…even if, at the same time, it's apparent there are still some pockets of resistance.

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CQC - From 'Requires Improvement' to 'Outstanding'

Claire Hughes, Critical Care Matron

If you've been following us for a while you'll often see us mentioning in our blog that one of the many ways you can recognise a good team is the fact that team members will take the time to tell their colleagues when they've done something well.

On this subject then, we feel it's important to walk the talk and congratulate one of the Trusts we've been working with for a while, The Critical Care team at Royal Stoke University Hospital.

Following their previous Care Quality Commission inspection, the leadership team, with the support of the trust made the decision to embark on a transformation programme to address the issues that had been highlighted.

As a result the CQC rating of their Intensive/Critical Care unit has been changed from 'Requires Improvement' to 'Outstanding'. Read their report here


Implementing Human Factors training combined with support for a full transformation programme has helped make this possible.


Claire Hughes, Critical Care Matron at Royal Stoke writes:


"The Critical Care Team at University Hospital of North Midlands has invested greatly in Human Factors training with the aim to have 50% of all staff trained in this topic.

Our unit has undergone a Transformation Program to bridge identified gaps between the General Provision for Intensive Care (GPIC's) guidance against a former baseline position. Specific work was required to address incidents both local and intra hospital.

Trevor Dale was able to provide an excellent foundation training schedule to address the issue and instigate 'Human Factors' as a challenge and change culture for our unit.Staff who have attended the training course are fully complimentary of the skills attributes gained from the overall experience and scenario based learning.

It is already evident that Human Factors training is positively changing everyday practices and culture amongst the many staff on our very busy critical care unit.

A recent Major Incident highlighted how significant communication and human factors was, to ensure patient safety in this complex situation. For this, we thank you Trevor and the team"


This Critical Care unit is a great example of how having the support of the leadership team and Trust when it comes to implementing positive changes through training can make a difference.


By approaching learning as an ongoing journey of development and not a tick box exercise you can make improvements that are sustainable. So congratulations to all the hard work the team has put in towards making it happen.

It's been an absolute pleasure to be part of their improvements and we are looking forward to our continuing to work with them.



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A Situational Violation



Picture yourself in this situation; you're an Anaesthetist who has been called to attend to a patient who needs an emergency C-section. There's a small window to act fast and save the baby, but you notice that the patient isn't wearing an identity wristband. Would you anaesthetise?



Before we go any further, consider this similar situation before making a decision on what your course of action would be. Again, a real-life story that we've been made aware of recently. 

A small boy and his mother are rushed into a busy A&E department at an NHS Trust, the boy having been mauled by a dog. The child is quickly referred to the Trauma Team and there is no doubt that they have the right child; he's covered in blood, bite marks, screaming and the mother is upset as you'd expect. They do what needs to be done, they do their jobs, clean wounds and patch him up. Afterwards, they find out he's got the wrong wristband on. 

The hospital decides to deal with this error with disciplinary action against the Clinicians. 

Take a step back and you can see how a small mistake like this can occur. A busy department, a small boy screaming, arms flailing about…he requires urgent medical attention and it's clear what he needs; but why go straight to disciplinary action, and if not a disciplinary then how should it be dealt with? 

Treating individuals of any specialty, nursing or clinician like responsible professionals is almost guaranteed to have a much better outcome. This incident should have been approached as something to learn from, a discussion point. A team conversation in which this error is highlighted and shared. An opportunity for staff to explore all the circumstances which led to the name check being missed, to think about the likelihood that this could happen again, and then if necessary, think about steps that can reasonably be taken to avoid a repetition of this error. 

Using a risk matrix can help differentiate between low frequency events with very serious untoward outcomes and those with much less serious outcomes. And of course, the risk of not taking action must also be assessed to give a balanced perspective.


Let's think again about the mother who needed an emergency C-section. 

On this occasion, the Anaesthetist refused to anaesthetise the patient because of the missing wristband, which lead to a ten minute delay while they got a wristband on her. The result of this, was that the precious opportunity to get the baby out safe was missed. The child is now permanently brain damaged. 

The easy thing to do is blame the Anaesthetist. He or she could have acted differently, taken a risk, broken a rule to act fast and then justified his/her actions later. Or perhaps the finger of blame points at the nurse or doctor who was responsible for making sure the patient had a wristband on? 


Of course, there's other elements to muddy the waters. 

What does this individual normally do? Flout rules or routinely demonstrate good practice? Do they have previous history which led to this particular decision? Were they previously involved in, or even just exposed, to a patient misidentification that resulted in serious harm? 

Patient misidentification is known to contribute to errors and is a cause of patient safety incidents; including operating on the wrong patient, or performing the wrong procedure, or performing surgery / an intervention on the wrong body part (e.g., right vs. left knee replacement operation). 


So what's the answer here? 

It's a tragic story and an upsetting, ongoing experience for all involved. We feel however that it highlights how easy it is for leaders to unintentionally get it wrong and in doing so, stopping professionals from getting it right. 

One major factor in high risk decision making has to be whether your front line team feel safe and supported. Now, what that means to us is that a management system needs to be set up and run in such a way that makes front line staff feel safe. This must be borne out in reality, as opposed to being implied and then not acted on when the time comes;


"Well of course you're safe with us, we operate a no-blame culture"


Saying it doesn't make it true. 


Did the Anaesthesist feel safe? 

If frontline staff feel they have to protect themselves first from disciplinary action or being struck off then that's how hospitals end up with staff who will refuse to do something that in hindsight would have been the "sensible" action. The sense of covering one's own back is a normal human reaction to a perceived threat and it is a clear signal that all is not well with the system. 

If individuals and teams feel safe and supported it will reduce stress and they will feel enabled and empowered to make better decisions. This not only means better care and outcomes for patients, but also builds trust and team morale. 


Join us for the our next Masterclass in London.

Atrainability are now working alongside Quality Improvement Clinic to offer a one-day Masterclass which combines Human Factors and QI Science which will be running on 25 June 2018 in London. Read more about the masterclass here or Register for the event here.

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HFE in Healthcare, Investigation and Education


We at Atrainability are proud to have been invited to sponsor the

Clinical Human Factors Group's upcoming Aberdeen Open Seminar on 23 May.


"We are honored to be supporting this event and pleased to be able to contribute towards the ongoing mission of the Clinical Human Factors Group" - Trevor Dale, Managing Director, Trevor is also planning to attend the event and he hopes to see you there.


Please find further details below:

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CHFG's next Open Seminar will take place in Aberdeen on the 23rd May 2018.


The Keynote speakers are:


• Keith Conradi, who will provide an update on the developing work of the Healthcare Safety Investigation Branch (HSIB)

• Dr Paul Bowie from NHS Education for Scotland and Craig McIlhenny at NHS Forth Valley Scotland, talking about the new national multi-agency initiative on Human Factors in NHS Scotland.

Breakout session topics include:


Dr Karthryn Mearns - Safety culture - we can measure it, but can we manage it?

• Manoj Kumar - Safety reviews: bridging the gap between work as imagined and work as done

• Professor George Youngson - The impact of bullying and discrimination

• Dr Helen Vosper - Human Factors as a strategy for improving Medication Safety

• Dr Alastair Ross - The Functional Resource Analysis Method and how to develop a model of everyday work

• Professor Ron Mcleod - Bowtie analysis as an approach to the assessment of the risk in healthcare

• Dr John Rutherford and Dr David Macnair - Good practice in running Human Factors training in a district general hospital

• Dr Shelly Jeffcott - Pushing back on "the way we do things around here": What holds us back from integrating HF/E


This one day event will focus on Human Factors in healthcare and applications in investigation, clinical practice and education.


Register for the event here & View full programme here.


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Unintended Consequences

(Revised: 15.2.18)

In the wake of the tragic death of Jack Adcock and the conviction and subsequent striking off of Dr Hadiza Bawa-Garba, we need to work together to rebuild the damage done to the safety culture. How? Revenge and blame feel great don't they? But neither of these options offers a solution to stop repeated errors. It is easier to point the finger at an individual, rather than a flawed system.*

Martin Bromiley is a shining example in seeking no retribution in the aftermath of the death of his wife, Elaine. Instead, he has made it his life's mission to educate others. 


It should be highlighted is that the mitigated circumstances which often lead to a tragedy, are sadly not unique.

The abnormal, such as multi-tasking, staff shortages, no handovers, hierarchy barriers etc…eventually becomes normal practice. We want to help professionals in all status's and across all aspects of health and social care feel safe and encouraged to report and aid learning from the most basic of human conditions, fallibility. 

Time and time again you've probably been told that near misses (near hits?) and incidents are the richest source of learning. Yet we still find that these often go unnoticed in all fields, sometimes because they don't get reported. Or, as mentioned by some professionals we've spoken with recently; it's because "human factors" is stated as the cause of the error yet it's not adequately analysed, or learned from and the true underlying causes remain. Perhaps this is a side effect of the abnormal becoming normal? 


I appreciate that too much has been made of aviation as a model. 

But one thing I would argue is indisputable is that the way the culture changed was by embedding human factors ergonomics principles in every single thing, from training through to all processes. My own son, flying now for a major international airline simply says "it's just the way we do it!" – but it took time to get to that stage. 

The term Human Factors is certainly more heard of and understood in healthcare than it was when we started fifteen years ago; but a one-off Human Factors course as part of a knee-jerk reaction or tick box exercise will not make sustainable changes.


It's one thing to say you know about Human Factors – but what actions are you taking? 

We're currently delivering long term training solutions with coaching and ongoing support to a number of NHS and private providers. Train the Champion and Train the Trainer as well as foundation awareness are helping to kick start that embedding process. It is terrific to see how general awareness is growing! 


But it's not all about error. 

It's important that teams understand why things "go right" too and how to repeat that. One organisation we've just tendered for are rated 'Good' across the board by the CQC, but they want to achieve 'Outstanding'. That's the way to go.

Please get in touch and let's see how we can help your teams. 


PS. *The British Medical Association has just launched an online space allowing doctors to report their experiences and examples of how the system is preventing them from providing safe care. https://r1.dotmailer-surveys.com/00jvxef-a92tly1f


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An apology regarding the earlier version of this blog piece sent out via e-mail on 15 Feb 2018:

We at Atrainability regret that we have passed on some mis-information in the earlier version of this blog piece, distrbuted via our e-newsletter on 15 Feb 2018.

Prof Terence Stephenson, Chair of the GMC made a statement on 2 Feb 2018 that in fact the e-portfolio reflective statement was NOT used as evidence against Dr Bawa-Garba. The GMC have clarified that the details reported in this case were not accurate.

Thank you to those of you who took the time to inform us about our error. We have amended the above post and resent out a revised copy of the e-newsletter to reflect this. Despite this unfortunate error, we believe that the potential damage to the reporting culture is still tangible and valid based on our conversations with a number of Clinicians.

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A ZERO fatality year...

Once again we've heard comments that aviation and healthcare are radically different, the point being of course, that healthcare can't possibly transfer learning from an industry such as aviation. Well of course our industries are different, but it's not as simple as some people think.

We've heard this so many times. 

"Pilots would not get airborne with a plane that wasn't working properly, where as Doctors and Nurses are dealing with people who've had something go wrong" 

This misses the point. 

Most people don't realise that if something goes wrong in an airplane, rarely do you see it coming and the chances are we're already airborne. 

Aviation in the 21st century is incredibly safe, so much so that there is talk of a zero fatality year worldwide due to accidents, leaving aside deliberate acts. 

Extrapolating this it suggests that aviation is, as is often claimed, 99% boredom 1% sheer terror. Not strictly accurate, but mostly things do not go wrong, but what flight crew have to maintain is a wary eye for potential problems.If they occur…

The enemy here is complacency. 

Flight crew, like healthcare teams, have to be like the proverbial coiled spring, ready to react, safely and sensibly in times of extreme stress and with limited options. 

In a nutshell, where learning from aviation can be beneficial and transferrable to healthcare is via our techniques and methods for understanding human behaviour. Being able to be proactive rather reactive, be situationally aware as well as self-aware, understand how to communicate effectively to avoid misunderstanding. 

These skills when mastered, can create leaders and teams who can make better judgement calls, minimise risk and maximise safety. Knowing what we do about the effects of the amygdala and fight, flight and freeze, it is the ability to control your actions under extreme stress that we have to practice. 

Preparedness is crucial. 

Flight crew are trained to consider what could realistically ruin their, and you the passengers, day. One of the aviation techniques is to use periods of low activity, not to simply chat and pass the time of day, but to discuss with your colleagues and your team what they might consider to be a potential problem. When flying how would we handle a depressurisation or a hydraulic system failure. In healthcare something akin to a cardiac arrest or pranging a major blood vessel, or an unanticipated allergic reaction for instance. 

Alternatively a challenging aspect could be when you know you're going to be working with a difficult colleague, so you could discuss in advance how you will try to change the trajectory of incivility into a harmonious team outcome. 

Atrainability are able to provide tailored Human Factors support for teams that are in need of advice, support or development.

Further reading...

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Improvement Science for Better Outcomes

Atrainability have teamed up with The Quality Improvement Clinic and QIC Learn to create a one-day masterclass which will show you how Human Factors and Improvement Science can help you deliver better outcomes.

Small changes can effect big changes and we can equip you with the knowledge and confidence to take new ideas back to your setting.

What will I gain?

After taking part in this masterclass delegates will be able to:

• Be inspired to use human factors and improvement science to deliver better outcomes for their patient e.g. during transitions of care

• Understand Threat and Error Management - an essential concept in learning from error and success

• Understand and accept the causes of mistakes -how to maintain confidence in the high pressure workplace

• Know the early warning signs that things are not as they should be and what to do about them

• Understand and adopt effective communication -ensuring mutual understanding

This 1 day masterclass has been designed to give you an appreciation of Human Factors in the workplace and how it can help you deliver better care.

Through attending this course, you are becoming a change agent, leading the way to help make your patients and your ward safer with Human Factors.

We look forward to you joining us on Friday 23 March 2018.

​BOOKING NOW:

Human Factors Principles + Improvement Science = Better Outcomes


When: Friday 23 March 2018
Where: De Vere West One Conference Centre, London

JOIN US:
Click to find out more OR
Click to book online

. **Special Offers** 15% Group booking Discount or 10% Card Payment Discount
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Debriefing - The Holy Grail

Debriefing or feedback is a vital part of ensuring teams communicate effectively and learn from experiences. How good are we at giving and accepting praise and positive feedback?

An insight I've gained from working with and observing teams is how surprised individuals can be when given positive feedback. Also sometimes they have real difficulty accepting it and view it as patronising. But feedback is a gift and let's be honest we don't do it well. Most of us are swift to blame and slow to praise.

Perhaps it's that quintessential Britishness which hinders us thanking or complimenting a colleague's contribution or skill? We are a very multicultural society now and what richness that brings, so perhaps we can move forward.

Being praised for good performance not only raises morale but improves trust and performance within the team and beyond. It can benefit sickness rates and staff retention as it has in some of our clients.

I recently had the privilege of watching a series of Maternity deliveries by C-section. After introductions during one of the safety huddle at 8am, I explained I was hoping to observe and help them recognise what they've done well – and so it proved to be.

The team were not anticipating any particular problems, and although the first mother had a history of previous C-section deliveries, a scan had been conducted to check the position of the placenta.

Unfortunately, when accessing the uterus they encountered Placenta Previa, and along with the accompanying significant blood loss it was discovered that the baby had inhaled some of the fluid. Rather than a healthy cry, the baby omitted a half-choking squawk and instantly the body language of the team changed and the call was made for the paediatricians to attend urgently.

To cut a long story short, I can report that all was handled extremely well and the baby was quickly whisked off and the outcome was a healthy mother and child.

Afterwards I was asked by the team for feedback. After going into some non-clinical detail on how they'd handled a tricky situation really well I then encouraged them to provide some positive feedback to each other. It did not come naturally, but eventually the Registrar agreed that yes it did go very well. When asked if she could tell me why, she looked stunned and after some thought replied;

"The Scrub Nurse did a great job and I had everything in my hand before I barely asked for it."

With some gentle reassurance, The Registrar relayed her positive feedback to the Scrub Nurse directly.

After being told what a great job she'd done she beamed and said,

"Firstly I'm a midwife, not a scrub nurse. I am only doing this because the scrub nurse called in sick today, it's not my normal job."

I said "Well you've just had some great feedback!" She then added "When they pranged the placenta my heart sank and I thought we were going to have real problems but what held me together was how calm the two surgeons remained as they handled the situation successfully."

Soon, the rest of the team started opening up about their own worries and self-criticisms during the procedure, all which were met with empathy as well as positive and constructive feedback from their colleagues.

The senior midwife had been acting as team leader and in a circulating capacity. She thought she had left it too long before comforting the mother and father. I commented that it did seem like a long time, but the parents had looked relaxed and unconcerned. However the only people who could comment were the parents themselves. How about go and ask them? They were in fact fine.

Everyone now professed that they felt so much happier and confident. They all had a much better team understanding. Everyone was smiling and the atmosphere was positively buoyant.

So what's the moral of this story? You don't really need a trainer to tell you what you've done well, but you might need some help to get your team to a place where positive and constructive feedback become the norm.

We'd be delighted to help you.

Atrainability offer both in-house and Open Course training and coaching solutions. We'd be happy to have an informal chat (in confidence of course) to discuss your current challenges. Please get in touch and one of our team will get back to you

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A renewed focus on NatSSIPs

NatSSIPs - National Safety Standards for Invasive Procedures 


Many of our prospective clients often tell us that they are working successfully towards a safer culture, and yet never-events and avoidable harm do not appear to be diminishing on a National basis.* 

Let's look at NatSSIPs and LocSSIPs on which there is a renewed focus at this time. Otherwise known as the Five Steps to Safer Surgery. 

LocSSIPs is a topic that we have masses of experience in, helping Trusts develop their own best practice in briefing, checklist and debriefing . We are privileged to witness many excellent demonstrations using Natsipps techniques but sadly, we occasionally meet individuals who think they don't need such aids to safety. 

Very recently I was disappointed to witness a Clinician quite deliberately reading news reports on his Smartphone while a Safer Surgery Checklist was being read. Sadly his clinical colleague said nothing. Rest assured that the situation was rectified at the time. However this is still not unique, though happily rare. 

We have a responsibility to ensure the importance of NatSSIPs and the reasons behind its introduction are understood. In our view (and others) the use of checklists and safety techniques is not a personal option, but a mandate and a necessary core function of professional surgical performance. 

NatSSIPs is built around the aviation based concept of threat and error management. This came out of the original NASA funded research at the University of Texas under the late professor Bob Helmreich. 


Threat and Error Management is three steps: 

•AVOID – in an ideal world you would avoid everything that could possibly go wrong

TRAP - But of course you can't avoid everything in the real World. What you haven't been able to avoid you would wish to trap, in order to minimise any errors resulting in potential harm. 

•MITIGATE (read definition)- Finally, one needs to reduce the effects if harmful but to stretch the meaning of 'Mitigate' – to learn from failure and of course success. 


How does this work in practice? 

In healthcare, as in aviation, the 'AVOID' phase is accomplished by having a briefing (Handover or Safety Huddle) normally performed at the start of a working shift or day. This is where the team get together, share plans for what should happen, build situation awareness (Plan A) across the whole team and prepare themselves for what they hope won't happen (Plan B, plan C etc). 

'TRAP' - The 3 steps of the WHO Safer Surgery Checklist fulfil this role.The checklist serves as a memory aid to ensure all necessary safety issues have in fact been completed. Note – it is a Checklist - not a TICK LIST. It is completion of the actual CHECK that is crucial and not the ticking of a box! 

Finally, 'MITIGATION'. Debriefing sits here as a tool for learning not blame. In the case of a successful outcome debriefing is the opportunity to discuss what went well, why it went well and how we will try to ensure it goes well tomorrow and thereafter. 

In the event that it has not gone well, rather than resorting to blame and finger pointing; this step serves to investigate why and how something went awry. How and why well-intentioned, well-trained people have perhaps made an error, with a view to genuinely learning lessons and moving forward effectively for the whole team and ultimately the organisation and the profession. 

Duty of Candour sits here too and is of course a legal, professional and a compassionate necessity. 

After all, quite apart from the safety aspect, who gains the most respect? Someone who accepts and owns up to their own fallibility or someone who seeks to hide it? 

Atrainability would be delighted to assist you in implementing LocSSIPs for your teams, please get in touch to arrange an informal phone chat at your convenience. 


*Source: Never events data, click here

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Walking the Tightrope...

Self-Confidence is vital but Self-Awareness is Key to Learning Success.

Confidence is a vital commodity when it comes to delivering safe, effective performance in any job, sport or profession. One must have a degree of self-belief in order to fly a plane full of people, compete in sports or indeed perform medical treatment. However, a simple, basic facet of being human is that we are all fallible.


Are we aware of our response to our own errors?

Firstly, we have to realise that we have indeed made an error, because initially whatever action was taken was likely done with the expectation that it was correct. The dawning realisation that we have indeed committed an erroneous act can trigger a response, which could be fight, flight or freeze. Once confidence is damaged, it can manifest in a variety of ways. If we have a critical voice in our head, telling ourselves off; compounded by friends, family or colleagues also berating us, we can spiral downwards into depression. Often if we are unable to accept that we're responsible for a mistake we can respond defensively by directing our responses outwards;


                                                          "Why didn't YOU tell me!"

                                                         "Why didn't YOU stop me?"

                                                         "YOU didn't tell me…"


…in other words, if I can't accept my own fallibility it must be yours. This in some cases leads to arrogant behaviour, and does not make for safe, effective teams.

We as individuals need to work on our self-awareness, take responsibility and manage our responses, but we also need a team around us who don't continue the cycle of berating and instead supports and learns when mistakes are made.

How has aviation dealt with this? By embedding Human Factors principles at all levels from Board to the frontline.

The Board must walk the talk or any transformation program will fail, because it is perception at the individual level of the safety culture that is crucial to success.

Pre-1980's aviation training focussed purely on the technical skills of flying a plane. Effective communication, team-work, situation awareness – these were not considered important. However, with the improved use of black box recordings and analysis of significant aircraft accidents it became apparent that it was the human element that was mostly at fault. What is now known as – Human Factors.

How was it dealt with? By educating flight crew and then embedding effective human factors practice in ALL technical training. Although it took time, it is now completely accepted as part of the culture. Furthermore regular refresher training, feedback and assessment is given to flight crew on their flying skills and their interpersonal and cognitive skills to keep best practice at the forefront of their daily practice. In terms of appraisals these are taken very seriously.

If a pilot fails to meet the standards in either category of technical or non-technical skills he/she will be given further training and ultimately he/she can be removed from service. Just imagine if this took place to the same extent in healthcare and some other professions.

The fundamental point though is to understand error and the causes of error, and to accept them and to work with them. Humility is an essential part of professionalism. One of our clients (a large critical care unit in a major trauma centre) has recently contacted us to say how our training has had an impact on their team.

Furthermore we've been told that staff turnover has been reduced to a very low level indeed. These changes have been visible after in-depth Human Factors training and coaching, although they cannot be directly attributed of course.

Atrainability would be delighted to help any team or organisation delve further into their own short-comings and help to highlight their areas of success. Contact us for an informal, confidential discussion or alternatively enrol for our upcoming Open Courses listed here.
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ITV Tonight - Medical Blunders & other updates

ITV Tonight - Medical Blunders & other updates

Here at Atrainability, we're pleased to say it's been an eventful few weeks.

ITV Tonight: How Health & Social care can learn from Aviation.

I recorded an interview with ITV Tonight, Click here for Catch Up.or alternatively watch here. The programme is focused on Patient Safety and my suggestions were aimed at helping explain some of the elements that increase the chances of human error in health and social care. Part of the interview was filmed in-flight to demonstrate why checklists are a vital and completely accepted aspect of safety in aviation.

Fallibility is of course an inevitable, though sad facet of the Human Condition. Accepting that and helping to avoid, trap and/or mitigate error is fundamentally what we at Atrainability are concerned with. Although the programme focussed on the NHS, we would like to be clear that we know and understand that private providers make mistakes to. We'd be interested in hearing your thoughts on the subject. Tweet #ITVTonight @atrainability or get in touch.

The Glasgow Emergency Surgery and Trauma Symposium

It was a great pleasure to be invited to take part actively in the 2017 Glasgow Emergency Surgery and Trauma Symposium where I gained so much valuable insight into complex post trauma care from some truly World-leading experts in both clinical and non-clinical skills. The latter involved Professor Rhona Flin from Aberdeen University. All the faculty were honoured, in my case by the award of Membership of the Royal College of Physicians and Surgeons of Glasgow.

Coaching and Mentoring in the Operating Theatre

Now we are helping an NHS Trust further develop their non-technical teamworking in association with their LocSSIPS, by coaching and mentoring in operating theatres.

One aspect of this has been debriefing a successful emergency C-section. On first asking "why did it go well?" the answer from one of the senior nurses was that it has "just worked well". However, so much more learning is available with careful encouragement.

In brief, the team had been widely scattered across a large area of the hospital when they received the 'Crash Call'. They clearly moved rapidly and had no time to lose. They didn't do a formal briefing but had in fact accomplished one which they set to work. They shared plans, updated Situation Awareness and allocated tasks to the appropriate team member. A good job achieved and a healthy baby delivered safely.

The work is continuing with debriefing and feedback on specific areas such as checklist design, development and implementation with guidance on how to maximise safety. Much effective work is being pointed out and reinforced as well as some corrective advice.

The Society of Radiographers - 'Putting Patient Safety First'

"When it comes to developing and changing a culture...simple changes can make things better." - Naomi Burden, Quality & Governance Radiographer at Royal Cornwall Hospitals. Atrainability are very proud to have helped progress Human Factors awareness in Radiography. Read the full article.

New Masterclass

We're now offering An Introduction to Coaching and Mentoring workshop which has been developed by Atrainability's Ben Tipney. More information will be available shortly on our website but if you'd like to find out more please contact us.

As always, we're happy to discuss any challenges you are currently facing or answer any questions you might have about our Human Factors training.

Trevor and the Atrainability Team.

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