Atrainability Blog

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

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.

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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.

A ZERO fatality year...
HFE in Healthcare, Investigation and Education


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Friday, 23 March 2018