Karen Speight Human Factors Training Consultant
Human factors are so embedded in our everyday life as well as our working lives. The other day I decided to tidy out my cutlery drawer. Everything was out on the work surface and, as the newly cleaned drawer was drying ready for re-loading, I decided to make a cup of coffee.
As I turned back to the drawer to get a teaspoon, my hand went straight into the empty drawer despite the fact that all the spoons were in full view on the work surface. An "action slip" during a routine task that has become automatic over the years.
Another example is driving to see my sister in Bristol, I am extra careful when I get to the junction with the motorway as more than once I've ended up travelling in the London direction towards Heathrow airport instead! I've learnt the hard way that it's better not to make (hands free) phone calls or listen to podcasts until after this critical decision point, or distraction means that the decision gets hijacked by what I usually do when I drive to work. How many parallels are there with these everyday errors in our working lives? Working with Atrainability, whenever anyone tells me that they have ever selected and administered the wrong drug I'm always interested in how the cupboard was laid out. Which drugs do they routinely give? Are there any other cupboards they use or have used before with a different layout? Or have they previously experienced a different labelling systems for the drugs? How deliberately was any cross-checking done? It's so easy to fall into a pattern of doing what we normally do rather than what the particular situation requires.
When I tell people that, as I pilot, not a day goes by that I don't make a mistake they are usually shocked - pilots "shouldn't" make mistakes! What about the safety of the passengers? However it is true, and we have systems and procedures that help to protect us from the consequences of mistakes such as checklists and briefing strategies that include rehearsing responses to possible mistakes. I actually wouldn't trust a colleague of mine that said (s)he didn't regularly make mistakes. After starting the engines one day at Amsterdam, a technical fault message came up on our computer that needed some attention. Due to the distraction, we forgot to select the flaps for take-off. During the taxi out to the runway, I spotted the mistake. We stopped the aircraft and quickly realised that due to the distraction we had not fully completed our checks. We re-ran the necessary procedures and checklist to make sure there was nothing else that we had forgotten and we then continued to taxi out and take-off without further issues.
A few days after the incident I had a discussion with a manager who was aware that several other pilots had made the same mistake - a technical fault had distracted them from setting the flaps until they were getting towards the runway too - and we discussed ways in which our procedures and checks could be tightened up to provide an extra layer of safety by making sure the flap selection was always completed before starting to taxi. These changes were subsequently made to our standard operating procedures to make them safer and more resilient going forward.
Why would anyone in any profession not admit to their errors? Unfortunately sometimes the culture is rather different in healthcare. We are all human. We make mistakes continually - it's one of the ways we learn so quickly. A fault turned into a strength if you like. Which person would you rather employ or work with? The one who had learnt from a mistake and was willing to share that learning with others and talk about how the system might be improved to prevent future mistakes? Or one that hid mistakes and errors thinking they were an embarrassing personal weakness? There needs to be a culture in place that supports openness - and a willingness to change the system to minimise error - if organisations, departments or operating teams want to learn from the rich source of information from colleagues on the front line who know what happens day-in day-out."