Human Factors MasterclassesBen Tipney Human Factors Training Consultant

Working with Atrainability has provided a real insight into just how challenging and stressful a job healthcare professionals have and it's given me a deep respect for what they do.

With mounting pressures year on year, understanding the 'human element' in patient outcomes is ever more important.

One particular story that sticks with me involved a near-miss event in surgery, where a member of the team was about to hand the wrong syringe to the surgeon but was stopped at the last moment by a colleague who spotted the mistake. The team didn't have any form of debrief, despite encouragement to do so - the reason given being 'these things happen - no patient harm occurred so we don't have time'.

Tragically, about a year later, in the same department almost exactly the same thing happened but this time no-one spotted the mistake and severe patient harm occurred, with a huge ligation claim as the result. I can't help but wonder 'what if'? What if they had extracted the learning from the near miss? Would they have prevented that incident? We'll never know, but there's certainly a good chance. That's why we encourage proactive debriefing to learn, particularly when we have a near-miss, because sometimes you pick up those trends, those latent conditions, those 'accidents waiting to happen'.

Recently I had a rather embarrassing human factors moment of my own, where my laptop turned off halfway through a presentation because it wasn't charging! It was plugged in, and the plug was turned on - but it turned out that plug socket wasn't working. Is that a technical error, or the result of an assumption on my part? I'll let you decide !

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