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Atrainability Blog

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

Workshop feedback 01

This is the reaction to one of our training days for the NHS Wales National Leadership Programme last week.

“I also attended the Human Factors Training on Thursday afternoon.(which incidentally was a brilliant afternoon and must be fed back effectively to staff who weren't lucky enough to be there) This is the area i work in and already the practice of the WHO checklist has been introduced and has seen great benefits in the Operating Theatre. 
However there are still improvements to be made and all grades to realise they have a duty to be involved, and as Denis Campbell stresses it is a tool that may need changing if the professionals who are using it feel it is not working, as in the Aviation business it has been transformed many times over the last 40 years. It has the ability to be brilliant if everyone comes aboard. 
The advantage that the aviation profession have over us is the Black Box, where every bit of what went wrong is recorded, so they know exactly where things went wrong and precisely at what point. We do have documentation and some equipment that holds data, but a lot of our errors are gathered like pieces of a jigsaw and not always 100% accurate. Communication and Reflection are our biggest tools and Horizon mirrored this with the scenario of a failed airway.(This again is a brilliant piece of work). Through all our roles we can find examples of things that went well, could have gone better, went wrong and must always reflect and learn from these and use this experience to pass on. 
An honest and open approach is one we must adopt unlike the Politicians!! I again ask the Managers to come out from their offices and look at the Work force i.e the Human Factors that are contributing to the patient care that is being delivered, all levels within the Health Board need to examine their behaviour towards patients and staff, as Denis Campbell said you don`t want to change someone`s personality but they may need to change their behaviour towards a patient or Team members. 
If staff are happy in their work, patients may have a better experience, if checks are done it should be a safer one too!!Its not rocket science, its so achievable if staff felt cared for this would definitely have a good effect on the morale and to the working day and in turn be really good news for our patients!! Sometimes we become so bogged down with all the politics we forget the basics and that is Care and this goes for patients and staff!! 
One of the exercises that we did as a group on the Human Factors presentation was "What makes a good day" and "what makes a bad day" Have a think with your Team members you may be surprised!! We can`t get out of this mess but we can hopefully make the best of it!!
We in Theatres are working on it!!!!!!!!”

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Blame or learning?

Blame or learning?
On a recent course a consultant clinician told me of a colleague who had made a genuine error and patient harm had resulted.
The clinician went to their own management and told the tale against themself with the intention of sharing learning and stopping the identical thing happening again.
The treatment they received can be described in a couple of words - blame and humiliation. 
 
Result - never again will that sensible honest professional ever confess. 
 
The more tragic result is the loss of such a powerful educational lesson.
 
The real lesson from high reliability professions is to seek to learn from every possible opportunity.
 
We get told these tales all the time on courses, where we have explained how errors occur and what the barriers are everyday to open communication and defeating inappropriate hierarchy.
 
Healthcare professionals all seem to have horror stories of their own. Some where they have committed the error, some when they have failed to intervene. There is so much learning out there. The vast majority appear to be human factors related. What a wasted resource. 
 
With training, management and teams can learn to shift focus towards a learning culture rather than blame. The result? An open reporting culture, with better communication and less repeated mistakes.
 
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How to avoid mistakes in surgery Horizon 22 March BBC 2

How to avoid mistakes in surgery Horizon 22 March BBC 2
 
The programme itself was very well presented but left the biggest question unanswered: If the evidence for using WHO Safer Surgery checklists is so compelling and use has been mandated, why do so many clinicians still refuse to use it? We are currently engaged by three Trusts that have problems with compliance with use of the checklist. They are not alone.
 
I ran three courses for doctors of various specialties this week gone with about 50 doctors in total. Each of those courses had at least one who expressed reluctance to use the WHO checklist, at least at first. In a way you cannot blame them. If their Trust introduced the checklist by email, as so many did, can you wonder at it? 
Treat people like children and they may just act like them. 
 
We find that treating healthcare professionals appropriately, listening to their concerns and worries gets buy-in. Also explaining what checklists are for, how to use them and particularly what can happen if they are used but not correctly can produce greater willingness to comply. 
In aviation the Spanair MD-80 crash at Madrid in August 2008 resulted ultimately from the crew not performing the pre-take-off checks correctly. The flaps were not set and the result was a disaster that killed 154 passengers and crew. http://www.fomento.gob.es/NR/rdonlyres/EC47A855-B098-409E-B4C8-9A6DD0D0969F/107087/2008_032_A_ENG.pdf
 
Similarly the Air Florida crash into the Potomac river in Washington DC in January 1982 was caused by incorrect checklist usage – the engine anti-ice was not selected on in severe winter weather. The engine intake probes were iced resulting in an incorrect (overreading) power indication. The aircraft accelerated too slowly, failed to get airborne and crashed into the bridge and the river.
http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR82-08.pdf
 
That’s the issue for aircrew, if they screw up there is a good chance they will die. That tends to get their attention.

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Course comments March 19

Course comments March 19
It is a delight to read the comments of the course I have just presented to just 6 middle grade doctors. The big question is where were their colleagues? 
Comments from today - “The things I learned in the course are all very practical and make sense. I now realize that in addition to technical competence, how important a part human and social factors play in the outcome of various situations. Proper understanding of human factors situation awareness, decision making process and team working can make a huge difference in the outcome of difficult incidents.”
Another “a very memorable and enjoyable course, very important for NHS employees to attend – to improve safety and relationships with colleagues. I plan to perform briefing, checklist and debriefing for my bronchoscopy list”.
My favourite is “Fantastic! Let’s get the Managers and Chief Exec on this course too”. That is a comment we often hear. However when one of our SHA clients invited Board members to a special day about a year ago – how many do you think turned up? Just 2 non-execs. How many apologised for the no-show – none.

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Zero Tolerance on Error

Zero tolerance on error

Jeremy Hunt was quoted over the weekend saying that there should be zero tolerance of error and comparison with the aviation professions was the starting point.

Let us be clear, in aviation error is expected throughout the system. But thorough training is put in place – initial and recurrent – and assessment of non-technical skills performance. All technical training has the non-technical aspects blended in. But also there is constant vigilance for system problems which damage the Safety Culture. All incidents and near hits must be reported and all reporters of error are encouraged and responded to.

How could healthcare teams and individuals be expected to maintain zero error rate if they have no idea what ‘right’ looks like? The vast majority of Trusts and Hospitals have not trained their teams at all in a meaningful way. This is abundantly clear when we go into operating theatres and wards.

Only last week I heard of a theatre sister who proudly announced that she ticked all the boxes and signed the WHO Safer Surgery Checklist so that “all the paperwork was correct at the start”!  It simply cannot be her fault – she clearly has no idea what the checklist is for and how to use it. I bet the local internal audit shows 100% compliance though, so that’s all right then.

A year ago we worked in a small DGH that had 100% compliance with theatre checklist. Not a single anaesthetic preparation room had a ‘Sign In’ sheet in it; the ‘Time Out’ was laminated and on the wall of every theatre – but never used; not one of the Consultant Surgeons had heard of ‘Time Out’ because they always left early for ‘The Boy’ to close up and nobody else ever bothered to use it.

How prevalent is this? Probably highly so. If you work in a department which does perform checks properly be pleased and spread the word.

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Mental Health 2013 Conference

Atrainability is the Main sponsor for Mental Health 2013 Manchester March 14 http://www.publicserviceevents.co.uk/241/mental-health. 
We get 15 minutes in the plenary session and a MasterClass in Human Factors to boot. With our current work to bring HF practical tools to all aspects of healthcare this is crucial to spread the word. 
Today I had a great reception from 70 odd psychiatrists in South Yorkshire. I find it amusing to talk practical HF tools like the sterile workspace concept - not allowing interruptions and distractions to increase error opportunities - with a group of psychiatrists. But it seems we do have a different way of looking at things. The same goes for the basketball video demonstrating our attention weaknesses.
Yesterday with another Mental Health Trust team we discussed using checklists and aide-memoires for such as checking the risk for removing service-users from seclusion. It seems there can be a distinct aversion on the part of the staff to get service users back into the normal part of the unit and the perception of risk is what weighs heavily on their minds. I heard one tale of a patient who was threatening to shoot staff so they wouldn't let him out. But someone pointed out that they were under obs in a seclusion room and couldn't possibly have a weapon!
But under observation for prolonged periods is itself a non-human-friendly task. We teach that the attention span is limited, possibly as little as 20 minutes for concentration. So is it any wonder that lengthy obs are not carried out well? Would it be better to rotate staff around jobs to break up the monotony and keep eyes sharp?
Another issue is being prepared for what could go wrong. I heard of a staff member getting thumped because he was observing a patient taking the air after a violent episode. But the staff member was standing with hands in pockets leaning against a doorway with no room to duck when the patient walked past him and just simply hit him. The two staff had been chatting to each other and had taken eyes off the task. Probably won't do that again, but somebody else might. That is why debriefing to learn is so important.
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What stops experienced medical staff caring?

Following on from my previous post on the Francis report...
 
What are the key elements of the Francis report? Care and compassion of course but what stops experienced medical staff caring? Demotivated, dis-empowered and feeling unloved by their own senior management perhaps? In failing healthcare establishments the staff on the shop floor are not listened to and they are anything but encouraged to report unsafe practice and dangerous practice.
 
When aberrant behaviour goes unsanctioned and is effectively tolerated the effect permeates the whole culture. It becomes one of not caring about poor performance, non-adherence to safe working practice  and inappropriate behaviour. It is corrosive and standards slip away. 
 
Today I have been to a private hospital where the long arm of the CQC has recently been felt. The  bosses are worried about potential legal action, but that is hardly the point. Care for patients who place their trust in healthcare professionals is what it is all about not the legal threat. It should be accepted that best possible safe care practice is the only way. What could possibly be argued against?
 
So I hear of senior clinicians who adopt slack practice that they admit would not be accepted in their NHS Trust. They shout, rant, rage, act like children if not allowed to run 'their' operative list in their preferred order without argument. They also act, dare I say it, like tenage lads - egging each other on to see how far they can stretch things. Actually I experience this in NHS hospitals as well, from people who preach professionalism but don't walk the talk and furthermore have no intention of doing so.
 
What is so utterly amazing is that they think that no-one in their teams notices.  Yet as an outsider when I visit everyone knows who the awkward so-and-so's are. Guys - it is no secret, everyone knows who you are. It is not too late to change, just try asking the people you work with for some honest feedback. 
 
Here is how to do it, referring ideally to behaviour not technical performance:
 
  • Tell me one thing I do well 
  • Tell me one thing I should do more of
  • Tell me one thing I should do less of 
 
If the only answers you get back are technical and not non-technical, perhaps this might be a message. 
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Celebrating success 2

Celebrate success 2
 
What a great afternoon, enjoying the company of 20 Foundation doctors and their tutor. 
One had experienced a Human Factors issue with wrong patient, wrong notes where she had been handed notes for a patient and what she was seeing didn't match. Correct presentation, wrong side (leg). Initial thoughts 'oh no the patient has developed the same problem on the other leg and I had previously missed it'. However this prompted a second look at notes and ID and of course they were for a different patient. Fortunate that the problem was apparent or who knows what might have developed, under conditions of doctor fatigue, time pressure etc. Small success but saved a major potential problem. Learning point - check the classic Loss of Situation Awareness Red Flags' - in this case differing information from two sources. The notes and mark one eyesight.
 
In the morning I had met a Medical Director who actually deals with unacceptable behaviour by his team members. He operates what is apparently a genuine Just Culture and receives emails and other contacts reporting bad behaviour, rudeness to staff and patients, non-adherence to protocols and checklists and poor hygiene.
 
 I thought at first it was too good to be true, but it seems not. He has removed three senior consultants who would not or could not mend their ways. What prompted this exemplary behaviour by the MD seems to have been a tragic error that he made many years ago. I don't know the details and don't need to, but this is not unique as a motivation. Now he presides over a multi-site Foundation Trust which has had publicly acknowledged problems in the past but seems to be well on the way to safe practice.
 
We are being engaged to conduct theatre team training shortly because despite best attempts a couple of never events have recently occurred. One in particular was down to the surgeon leaving theatre before completion of Sign Out. The swab count was incorrect and a small swab had been left in the operative area. The theatre team had tried to no avail to keep the surgeon present but he had declined and left. This is what checklists are about - checking quite literally that things are not omitted or forgotten. It is not an insult to professionalism, but quite the reverse. Simply an aid to safety and fallibility.
 
Lesson - cross check, swallow pride and act professionally, not like a spoilt child.
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Francis Report 1

Francis Report 1
Will Francis be the 'sentinel' event that changes the healthcare culture in the UK to one of  patient safety-centred learning? This is the big chance to really refocus and eliminate the old-fashioned views around working practice.
As an outside observer and trainer in healthcare for almost 11 years I have been amazed at the attitudes espoused by people from  nurses to senior clinicians and above. It is as if nothing can be learned from safety-critical industries and this attitude is still highly prevalent. Thank goodness the number of enlightened individuals and in some cases, organisations is growing. I sincerely hope that the current impetus to change the culture of blame and over-regulation can build. 
W hat does Francis have to say? "They will do everything in their power to protect patients from avoidable harm" - and how exactly does that translate to the real World? How does a HCA deal with a Doctor who tells him where to place his checklist? Will management support? Will non-adherence to safety tools be dealt with? It all sounds great but how? Not more regulation please!
We treat professionals as intelligent adults but I wonder if they have been treated not so for too long. Consider the 'mandatory' WHO-led Safer Surgery checklist. I believe the reason that it is incorrectly understood and therefore not properly used is lack of education. How many hospitals introduced the WHO checklist by email? Quite a few, and the result is we are invited in two years down the line to try and improve understanding and adherence to safety guidelines and procedures. Three hospitals in the last month, all of which have had recent serious incidents or 'never events'. 
I have recently heard of an emergency ectopic pregnancy procedure carried out in the early hours where the wrong side was operated on. The problem of course had to be dealt with and the young mother is now unable to conceive ever again. Tragedy. The team said they would have used the checklist had it been daytime. Bizarre. The use of the checklist should be everytime such that it becomes 'the way we do things here' - everywhere. Another I heard of yesterday - injection in the wrong eye. What made that one so bad was the alleged statement by the clinican that it was 'just one of those things'. 
We must not tolerate avoidable harm. There is simply no excuse.
We want to celebrate success. We want to hear when the team have insisted on the correct protocol whatever it is - checklist or not. 
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Celebrating Success 01

Celebrating Success 01
 
Why is it so hard to get journalists interested in the good news stories? I mentioned this  to the editor of a health publication recently and he grinned and said "not good journalism". Really? They tried it recently on breakfast TV and made a joke out of trying to find good news. Well if we continue in that vein we have no chance of really saving the NHS. So we are going to start publishing success stories about individuals and teams where people have saved the day and indeed lives.
 
A laparoscopic procedure went wrong when one of the ports punctured the patient's aorta. The scrub nurse immediately called for the Crash Team  and disregarded standard protocol of counting swabs, because they were being used so rapidly. Instead she announced loudly that she was just counting the strings. This is termed a 'situational violation' - breaking the rules for an exceptional problem. I believe this can be quite supportable in exceptional circumstances, provided the perpetrator announces the action. This should save other team members using limited spare cognitive resources wondering what is going on. It also gives the chance for someone to offer a different opinion and maybe challenge the logic. In this case the patient was saved and was sitting up in ITU the following day. Great save team.
 
So what could we learn? Well who was the ‘leader’? Some teams and individuals get quite hung up with hierarchy issues. I believe the leadership should move around the team depending on the situation. The worst option would be no functioning leader at all! Here you have a scrub nurse who may be quite senior and certainly appears experienced, who is prepared to take the lead at a critical stage. How do you debrief afterwards?  Let’s try this:
What did the team do well? They reacted quickly and called for help when needed. A member of the team was prepared to step up and make a swift crucial decision.
What could they do more of? Discuss possible problems and practice emergency drills - in this case if the worst happened and we punctured a critical organ, who would do what?
What could we do less of? Perhaps start a procedure without appropriate planning – in this case double checking port location?
 
Please note the focus on learning rather than blaming whoever pranged the aorta. For plenty of successful organisations within and outside the NHS celebrating success is a given. How do successful organisations succeed and keep on doing so? They encourage, empower, listen and ..... learn.

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Medical Protection Society

Medical Protection Society

Atrainability and MPS have forged close links and have developed 'Understanding Human Error in General Practice', a bespoke training course for healthcare professionals across the UK and Ireland.Understanding Human Error in General Practice aims to improve the way teams work together. The objective is to gain an understanding of the importance of human factors in reducing healthcare professionals’ exposure to complaints and improving patient safety.

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SafeGuarding

Teams involved with safeguarding children and vulnerable adults suffer from the identical human fallibilities such as are prevalent throughout healthcare.

Typical failings are:

  • Cognition errors leading to erroneous situation awareness – failing to recognise symptoms of abuse
  • Intuitive decisions which would benefit from analytic review
  • Hierarchy challenge issues
  • Interagency communication problems
These same issues are present in other high reliability professions and are most highly developed in aviation.
Atrainability have structured training programmes for:

These same issues are present in other high reliability professions and are most highly developed in aviation.

Atrainability have structured training programmes for:

  • Training Safeguarding practitioners
  • Training Safeguarding ‘Champions’
  • Training Safeguarding Trainers
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Staff Grade and Associate Specialist Doctors

Atrainability are the premier providers of Human Factors training for Staff Grade and Associate Specialist Doctors. The two day highly popular interactive course attracts 12 external CPD points 

Course Overview

The programme is designed to be interactive throughout and result in practical skills developed from those mandated in over 40 countries to enhance commercial and military aviation safety. The tutors will make use of video clips and case studies from various industries to highlight specific issues and encourage group discussion and self-motivated learning. The course is designed for up to 20 team members

 

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Ward Teams Training

HF Foundation course

An understanding of the patient safety issues involved with human fallibility
Practical tools for leadership of the patient care team
Handovers – avoiding the threats to safe handovers
Communication skills aimed at levelling the unnecessary hierarchy
Assertiveness skills
Avoiding interruptions and distractions
Effective decision making
Tools to help avoid and trap misdiagnosis and delayed diagnosis
Briefing the team to gain optimal high quality efficient work distribution
Debriefing the team to capture the first hand learning
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EPICC –Error Prevention In Complex Care course

This course in clinical team leadership has been designed to provide emergency physicians with the skills to manage and lead an unrehearsed multidisciplinary team who assemble in the resus room to manage critically ill patients and receive ambulance alerts.

The course is classroom and simulated role-play based with opportunities to put practical lessons into play.

Human Factors experts working together with emergency physicians have created this one-day course to give emergency physicians the practical skills to manage competing interests, challenging personalities among team members and to maintain control in the resus room to ensure the delivery of optimum multi-disciplinary team care to critically unwell patients.

Feedback evaluations of the course have been highly positive and repeat courses have been delivered at two venues.

Contact Atrainability for booking information. Please note the course is not currently run on an open basis, but only for Trusts. 

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