Atrainability Blog

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

Beware asking leading questions

I had a pacemaker fitted about four years ago.

The nurse that checked me into a private hospital for the procedure told me my name; "Hello, it's Mr Trevor Dale, isn't it?".

She proceeded to tell me my date of birth too, and what I was scheduled to have done that day.

After confirming "yes" to all of her questions, I asked her to start again and ask me my name instead of telling me my name, as she was supposed to. She responded with "yes I know I'm supposed to but …" Clearly, she didn't understand how dangerous that can be. How many times has the wrong answer been given because often patients don't like to cause upset' or they're merely stressed or ill and didn't hear correctly, or just didn't want to argue? The doctor knows best?

Many of you have had this particular issue where you've ended up with the wrong patient or made incorrect assumptions.

There's a funny story of a gynaecologist running a clinic in a part health care, part social care environment. She entered the waiting room and said, "Mrs Patel," and this woman said, "Yes." And she said, "Please would you come in and would you get undressed? I'm going to examine you."

The gynaecologist gave her patient a hysteroscopy and said, "Everything's fine. You'll be pleased to know no problem at all." And the lady said, "But I came here for housing benefit?"

And of course, it's the wrong, Mrs Patel. By the way three days later, a lawyers' letter arrived – invasive procedure without consent!

Over the years, I've met a lot of people in health care and social care who have experienced the same issue.

A consultant doctor recently told me he ended up telling a patient he had terminal liver cancer. It was only when he said to him, "Would you like to look at your scans with me?" that the patient told him he hadn't had any scans, and the doctor realised he had delivered such bad news to the wrong person.

Healthcare professionals are often embarrassed to ask their patients, "Could you tell me your name?".

I observed an ODP, a few years back, saying to a patient, "It is Mrs Jones, isn't it? Your date of birth is blah. And you're here to have your left knee operated on aren't you?"

Which is fine, but his colleague I went with separately said, "Now I know you're going to hear this 20 times today, Mrs Smith, but this is just for your safety, could you please tell me your name and your date of birth and what you think you're here for?" Which of these approaches do you believe is safer?

I observed another interesting one, only last week, where there was a chap who was very ill, with sepsis amongst other things and a kidney stone and multiple comorbidities. He was under heavy sedation at the time, and the ODP asked him, "Why are you here?" Of course, he didn't know and said as much in reply.

One of the ODPs asked the question in a much more effective way; "Do you know what's wrong with you?", to which the patient explained he had been told he had a kidney stone.

There's another case we know recently where a junior doctor went and consented a patient, said, "It's your right leg, isn't it?" Yes, here's an arrow on your leg. They got the consultant to countersign the consent.

The patient had dementia and didn't know if it was Christmas or Easter, let alone which leg it was. And of course, as luck would have it, it was the wrong leg.

Asking leading questions is part of human nature. It's a quick and easy approach, rather than what we prefer to see during a team briefing or safety huddle, which is "Does anyone have any concerns?"

So instead the lead says, "You're happy, aren't you?" It's closing the conversation down. People got to put a real effort in to ask a question or say they're not happy.

Whereas if you say to someone, "Do you have any concerns?", it opens up the conversation to the rest of the team.

Bearing in mind that some people are more reticent, and need to think things over and weigh up whether they're essential or not in their minds, then it's allowing them to speak up, especially if there's any level of hierarchy involved.

This issue of leading questions ties in with different nationalities and cultures experiencing different attitudes to people in authority, something identified by Hofstede's work on power-distance and nationality.

There was a Swedish lady on a course only last week, and she found all this stuff about deference to people in authority to be quite funny. And I said to her, "Do you know that the Swedes have the lowest inbuilt attitude to hierarchy of all the nationalities in the world?"

Her attitude in an open class discussion was precisely that as a Swede, and the Swedes do have a very flat hierarchy. And if anything, I think it can produce the reverse result, where they have difficulty showing appropriate respect to people in authority.

The consequences of asking leading questions can be pretty alarming, so please don't do it! Always ask open questions.
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Magic words

Being a pilot has been described as being 99% boredom and 1% sheer terror, but it is rarely both – honest! However, like healthcare, it is fundamentally about managing risk and therefore managing workload.

In the world of aviation, we have a magic word - "unable" for those rare occasions when we cannot comply with, for instance, air traffic control instructions.

If air traffic control instructs the pilot to turn left, or climb, or descend, and for any reason, the pilot can't do it (for a technical or weather-related reason, for example), then the pilot will say "unable".

If you've watched the movie 'Sully' the miracle on the Hudson, you might remember Captain Chesley "Sully" Sullenberger using the magic word "unable" when requested to turn to Teterboro airport. He uses the magic word, and nobody questions it.

Here at Atrainability, we've been introducing this Magic or Safeword concept to healthcare for some time. Critical teams could usefully have a magic word in place so that they can communicate effectively during procedures.

Of course, there needs to be a degree of sensitivity in choosing this magic word. It might upset a conscious patient to hear "Gorilla on the loose" or similar.

Some teams use the phrase "stop the line." This approach comes from the Toyota production line, where any member of staff is empowered to halt production if they see someone unsafe, inefficient, or ineffective taking place.

Some are using "10,000 feet", a reference to the other much-used aviation phrase that signifies no distraction or interruption for the time being. It comes from standard practice when commercial planes are near the ground – below 10,000 feet altitude. That's roughly the first and last 10 minutes of a typical flight.

We have the evidence from countless 'black boxes' that you're more likely to have an incident when not focused on the job in hand. In aviation, either enjoying the view "ooh look there's my house!" or discussing something inconsequential.

But "stop the line" or "10,000 feet" can be quite cumbersome and perhaps a little imported. It's preferable, I believe, for teams to devise their magic word.

There's a surgeon I know in one NHS hospital, as part of his daily team briefing, he asks what magic word they will use that day. That's a great approach to get teams to engage with magic word principle, but of course, if members of the group switch over during the day, it can be potentially problematic if someone new doesn't know the magic word of the day.

Some hospitals have a magic word at an organisational level. But that could feel like it's being imposed upon them. There's so much in healthcare where people need their independence, for their motivation and empowerment.

What matters is that every member of the team should feel able to stop what is taking place if they think anything is unsafe, or something needs to be clarified. They might say "unable" or "stop".

My wife and I have a magic phrase in case of emergency.

During a recent holiday, she said to me, "Trevor, I need you to help me!" She had caught her finger in a sunbed, causing a nasty injury and lots of blood when it was released. By saying, "need!", there was no doubt she need help Now. No confusion, no uncertainty.

Clarity is so important.

When you're piloting a plane and taking off or landing, your focus is quite reasonably ahead of you, so you're not making eye contact with your colleagues on the flight deck. Naturally, that means you can't detect non-verbal language like shifting in your seat with concern, as we would in ordinary life.

The same could apply if masked and gowned in a complicated or stressful clinical procedure.

When you use a Magic or Safeword, it's essential its use doesn't result in resentment from colleagues. We've got some way to go within the healthcare profession to understand this. Some cultures find it harder than others to accept the use of a magic word without associating it with disrespect or failure to follow a hierarchical structure.

So, to summarise, have you ever experienced a situation where someone either didn't speak up and challenge or wasn't heard or was misunderstood. With hindsight would a Magic or Safeword possibly have helped? I know some of you have got this already. Please spread the word!

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Sharing best practice

I spent some time in a major NHS Trust the other week, delivering two days of training at a large hospital.

The training involved very senior management, and I took the opportunity to mention the recurring incident which involves two syringes of colourless medicines being mixed up on the scrub tray.

I asked the senior management in the room, "So how do you do it here? Do you colour code the syringes, barcode them, or add labels?"

A senior nurse in the room spoke up, explaining she put Steristrips on each syringe and writes onto these. But there's no standard hospital protocol, designed to prevent the potentially severe mix-up from happening.

Sitting in the corner was the senior manager responsible for all elective surgery in this hospital. She sat there with her mouth open, realising there was no guideline in place designed to avoid or trap an easily preventable mistake.

I had an email exchange with her the following morning, and she confirmed she had a team working on the problem straight away.

What if I hadn't delivered training at that hospital? What if she hadn't attended the course that day?

Sharing best practice and national standards are sadly sorely lacking in the medical profession.

We're aware of another hospital, where recently an anaesthetist told me she administered a child with Adrenaline, not Fentanyl. This is important because Fentanyl is an opioid, slowing the heart rate. Adrenaline speeds it up.

Following the medication mix-up, the team were questioning why the child had become tachycardic, thinking something must have been seriously wrong with him. Only on return to the anaesthetic prep-room was the mix-up noticed.

Probable cause? Working with a new ODP, who drew up the drugs in an unfamiliar way and cross-checking was secondary to social team building.

Sharing best practice is so important. It is a shame that there is rarely time for medical professionals to spend a little time down the road with their colleagues at other hospitals, learning from the way they do things.

You attend a conference, and someone will often share best practice. But they tend to talk about their own hot topic, their specialist research area. It becomes hit and miss whether you attend relevant sessions.

There are locations around the country, and indeed around the world, that have solved significant issues. But sadly all too often others don't know about it.

This reminds me of the famous Donald Rumsfeld statement, about the 'known knowns' and 'unknown unknowns'.

Working out your unknown unknowns by sharing best practice between different teams is a really valuable but arguably essential step.

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Learning from near-misses

I was delivering some training recently at a hospital which was using the latest version of Datix, the instant reporting system. They have the newest release in place, which allows you to report no-harm, near-miss incidents; something the old system would not let you do. We checked the drop-down menus together and confirmed this capability was included.

During a quiet moment later that day with the senior management, I asked about their near miss reporting. They gave me a puzzled look, and asked what I meant by near miss?

When I explained what I meant, they told me they didn't do that. This prompted a conversation about how near misses are the luck element that results in not harming patients.

It became clear that the management at this hospital had not thought of near-miss reporting in this way before. They were bright people and very nice people, very well-intentioned, but it just hadn't occurred to them.

What it seems we often do at Atrainability is point out the obvious.

By getting members of critical teams to think about those danger areas they already know about, and they need to be proactively addressing, it helps them recognise the tip of the iceberg.

These are the dangers sitting right in front of us. But the real threat is submerged below the surface. When no harm is done, there are no visible means of damage caused.

Analysing near misses comes back to root cause analysis. There will probably be several underlying conditions at play.

For example, if you have a nurse who is going to be scrubbing with a surgeon, who has never carried out that procedure before, compared with a nurse who has. The nurse who has carried it out before is likely to know what the surgeon needs next before they even ask for it.

In that scenario, it's important to know before you get started whether your colleague knows what they are doing, or not, because in one case it's going to be a bit longer, and require a lot more communication.

From my background as a pilot, a mandatory reportable incident is anything which had the potential to cause harm. It's all about that word, potential.

Where potential to cause harm is identified in the medical profession, it's essential those near misses are analysed and understood, before changes are introduced to reduce that potential in the future.

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Bumpy landings - the importance of a Plan B in aviation and medicine

Last week was another small watershed for me. I flew a light aircraft for the first time in a year.

It was of course with an instructor and I am now checked out and legal to fly for another year. I plan to fly again next week, with friends.

The hiatus was because the last time I flew I didn't do it well.

The weather, a year ago, had been admittedly not great, gusty and bumpy, and I didn't handle it well and the consequence was my inner confidence was damaged.

Yesterday the weather was perfect. No clouds and almost no wind with excellent visibility.

Flying light aircraft is quite high risk. Only one engine is not nearly enough!

Fresh in my mind yesterday was the picture of the burning crashed aircraft splattered across the M4 in South Wales. They all survived. Phew.

The instructor instils confidence. He used to fly and instruct on Concorde. Knows a thing or two and particularly how to rebuild confidence.

I've been flying solo since 1967 close to 52 years but that balance between confidence and arrogance is a very thin line.

But there's other stuff in play here.

I fly with a small flying club. Their insurance dictates I need to do three landings in 90 days to be qualified.

The National regulator – the CAA – requires that I fly with an instructor once a year and fly 12 hours in the next 12 months.

Oh, and I need to pass a basic medical too. Last week I flew across country, just a few minutes to get used to handling again, then flew several circuits and landings including two non-normal ones.

One was without landing flaps – practising in case they fail one day and another simulating engine failure. The instructor checks I can do it but also it builds my confidence.

Some of those I meet who criticise the comparison between aviation and medicine would do well to consider all that.

The other main message which fits anywhere – always have a plan B.

Like knowing I could cope with a mechanical malfunction or weather-related problems.

Much as I love flying the one thing I always do is consider what could go wrong and try to be one step ahead. I don't always succeed of course and that's when I get worried.

No, it's not paranoia it's experience and good training.
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Culture and climate

We often hear our clients talking about culture. And people say individuals can't change a culture.

In my mind, changing culture is a bit like eating the proverbial elephant - a little at a time.

Instead of thinking only about culture, it's important to consider the climate too. That we can influence.

Culture is probably something stemming from the organisation. But climate, that's what's happening here in this room, right now.

You can influence climate at the start of the day, for example, by whether or not you smile and make eye contact. 

Climate is affected by whether or not you take an interest in others not just yourself. Effective leaders are like actors. They think before they enter a room and focus on what matters not on themselves alone. A smile is the simplest act.

Icebreakers affect climate. They might not affect culture, at least in the short-term, but they can and do change the climate. That's why basic politeness and making sure everyone knows everyone's names is so crucial. It should also set an appropriate hierarchy gradient.

I recently spent some time working with critical teams in an NHS hospital north of London.

They had been working with an interim unit manager, and I was told this individual had some perfectly valid ideas. But the way they presented their ideas was very aggressive, very authoritarian, and managed to destroy morale in the team.

Everyone was left feeling hacked off. The effect was palpable.

A new manager, above this theatre manager in the hierarchy of the hospital, was appointed and got straight to work doing what I thought was an excellent thing.

First of all, they asked the clinicians and staff what they thought. They had also heard from the chief executive that members of the team were unimpressed, but they took the time to speak to individuals to understand their views.

I heard from someone else that this approach gave the new manager tremendous credibility. Engaging like this with the front-line staff, while not entirely unheard of within the NHS, is it seems , all too rare, particularly of course in dysfunctional areas.

And the front line staff all told the new manager, "We're finding it impossible to work with this manager. They've made life here very unpleasant." The services of the team manager were swiftly dispensed with.

Fortunately, they were agency staff, so this process was straightforward, and the individual responsible for the negative climate was dismissed within a couple of days. It's at this point they asked Atrainability to come in, to work on a rebuild.

It was a very pleasurable experience because there was nothing wrong with the people themselves. They weren't in any trouble for making frequent mistakes, so our role was very much to emphasise the positives.

On that note, a small but very positive thing happened while I was there.

I asked, "What makes your day go so well here?". A couple of people in this room of 30 pointed to their new theatre manager, and said, "You know, Bill has made such a difference. He's so good to work with."

I had just been talking about the difficulty people experience in accepting praise, and of course, Bill turned to them and said, "No, no, no. It's not me; it's you!", the typical response we expect to see from those who struggle to accept praise.

I didn't say a word at that point, because it could have caused Bill some embarrassment but then when we broke for tea this happened: Bill asked if he could say something to the room.

Bill turned to his colleagues and said, "I've just done exactly what Trevor said. I shrugged off your praise. What an example! I just want to say to everyone; thank you so much for saying nice things about me."

It was a fantastic learning point; unscripted, but he had just gained another level of self-awareness.

Everyone in the room appreciated it because they saw a real-world demonstration taking place right in front of them. And we all had a really good laugh, with an immediate positive change taking place to the climate in that room.

It just shows what happens when you emphasise the obvious.

This is the reinforcing that leaders of critical teams need to carry out. They need to accept praise too, and then react accordingly, being a role model for their teams.

Remember, you can have a personal impact on the climate, every day.

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Hierarchy and behaviour issues

Inappropriate and unprofessional behaviour is cited as a problem area across many professions, and health and social care is no exception.

There are two significant aspects to consider – why do people behave inappropriately and what effect does it have?

Taking the first of those it could be just plain awkwardness in that they can get away with it, or perhaps they think it's harmless and just a stress-relief and fine if they apologise.

Could it be a lack of insight?

Shortage of emotional intelligence could be present perhaps because no one has ever told them?

Alternatively, it could be a result of illness or stress.

We know of one older person whose behaviour changed for the worse and ultimately it transpired they were suffering from an aggressive form of cancer.

The evidence is of course crucial. The excellent work of Christine Porath demonstrates the devastating damage done to performance and motivation.

Cognitive function diminishes by over 60%, and almost 40% of people on the receiving end of bullying intentionally reduce their performance.

There is however another aspect – could I be part of the problem?

Is my behaviour winding you up? That is, for some of us, a tough question.

The Atrainability training works through the root causes and helps delegates to consider their contribution either directly considering more effective behaviour or by not helping 'difficult' colleagues adapt their behaviour.

For managers, perhaps the realisation that they need to deal with the inappropriate and unprofessional behaviour is the critical message.

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Appreciative inquiry and accepting praise

Learning from excellence through the practice of debriefing is a hot topic in healthcare teams. We hear this being referred to as appreciative inquiry; a model that seeks to engage stakeholders in self-determined change.

The model assumes that the questions we ask tend to focus our attention in a particular direction. 

Organisations then evolve in the direction of the questions most persistently and passionately asked.

I'll often ask the healthcare professionals who attend our training courses whether they have a chat at the end of the day about how things went? "Yes, of course, we do."

But do you have this conversation in any real detail? "No, not really". 

You would, we hope, if things have not gone well but how often is that? Maybe 1% of the time? 

So, we don't really discuss the 99% of times when things go well. What effect does that have on morale?

At Atrainability we recommend three simple questions:

-Is there one thing that I or we do well?

-How about one thing I or we could do more of?

-Or maybe one thing I or we could do less of?

The crucial word is of course 'could'. Not 'ought' or 'should' because that is telling someone how to behave and no-one likes that. 'Could' makes it a suggestion, a nudge, if you will. Not a command. 

Adult to adult conversation in practice. Thoughts offered with honesty and accepted with humility.

Naturally, people generally debrief if thing went wrong. This is good practice, far better than the alternative of sweeping the error under the rug.

But how often does it go wrong, rather than right? If we assume things go right 99% of the time, then most of the time these conversations, and any appreciative inquiry, are rarely taking place.

We want to be having these conversations. "It was really great when you pointed that out and said I was wrong. Do that again, please."

This is about reinforcing positives, which people don't do often enough.

Another challenge, especially within the healthcare profession, is that people don't accept praise. They shrug it off. "I was only doing my job".

Perhaps this is a cultural thing for us Brits, making us feel uncomfortable when someone heaps on the praise. 

It's certainly a cultural issue within healthcare where we become so used to the extraordinary, it becomes ordinary.

Last summer, an extraordinary video of a nurse in the accident and emergency department at Leicester Royal Infirmary went viral on the Internet.

It showed 36-year-old nurse Caroline Clayton-Barker, along with several of her colleagues, putting herself in danger to protect patients from a man with a knife.

At one stage in the video, she comes face-to-face with the knife-man, before running to safety herself.

Despite Clayton-Barker later recounting that "It was like a horror film," she also told reporters she was just doing her job. "I don't feel brave, it's just your job, it's your duty of care to protect your patients."

In reality this was way more than 'just her job'; the lady performed exceptionally.

But on a more mundane level team members are doing great work daily but often just shrug it off.

We know that morale is low within the NHS. Staff recruitment and retention are both a huge challenge.

You can argue that working in the healthcare profession is often a thankless task. Nobody is saying thank you, and nobody is accepting the praise. This creates a vicious cycle.

If we don't accept praise, I reckon we get in the habit and don't offer praise as well.

Having the end of day conversations on the 99% of occasions where things went right, giving praise, and accepting praise, these are all excellent ways to get better and all feel better.

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Near hits and the tip of the iceberg

When things go wrong in healthcare - administering the wrong drug, treating the wrong patient, operating on the wrong site or patient - these are the mistakes we see. Sadly, avoidable harm is not decreasing and the annualised cost increasing in our litigious society. £2 billion outgoings for NHS Resolution in 2018, up from £1.7 billion the previous year.

What people often don't do is report the near misses, or near hits as we prefer to call them.

There's plenty of understandable reasons for not reporting the near hits.

Firstly, nothing has actually gone wrong. It's hard to report a near hit when it didn't result in a bad outcome for the patient.

Secondly, reporting systems tend to be very cumbersome and time-consuming; not something you would look forward to at the end of a long shift.

The boxes within these reporting systems don't always fit the scenario. When no actual harm has taken place, some of the older systems don't have a way to report the near hit from their drop-down boxes.

Another major reason healthcare professionals fail to report the near hits is because nothing tends to happen when the issue is raised. All too often, there's no reply to acknowledge the report or even say thank you.

If there is an acknowledgement, frequently nothing is seen to change. From a management point of view this can be frustrating because not all solutions can be visible. We know of a case of senior management following due process with a case of bullying but they can't publish that they put a warning on a personal file because naturally that is confidential. But staff see no change in behaviour of the culprit so don't waste time offering follow-up reports!

One more reason; when you report near hits, you don't always feel safe.

We are aware of one situation, involving a clinician working with a new colleague. They were chatting together, slightly distracted, and the new team member got the controlled drugs out in a different way.

The clinician knows they should have checked before administering the drugs, but they were distracted. They gave the wrong one of the two colourless solutions to the patient. Fortunately, there was no lasting harm to the patient, but this was a near hit.

The clinician decided to report the near hit. They were aware that the same had happened with some of their colleagues in the past. Human factors were involved, with a weakness in the drug-labelling system making the error easier to occur.

The result? After reporting the near hit, the clinician came under scrutiny from senior management. They were not thanked for raising the near hit. Instead, the management started looking into how many near hits the clinician had previously reported, comparing their frequency of reporting to management.

The irony in this is, they made the clinician who reported the near hit feel victimised. Yet management still went ahead and changed the process, to reduce the risk of the same near hit retaking place. Dishonest management in our opinion.

When I was flying jumbo jets with my former employer, there was a company policy of error reporting ethics. If you made a genuine human error and confessed it, you would not suffer any disciplinary action or consequence to your career.

If however you deliberately broke the rules or made an error then tried to hide it, you would be facing due process. And quite rightly too.

Airlines too, recognise the tip of the iceberg issue. If a near hit is reported, it's likely to be part of a much bigger problem, hiding below the surface.

The more comfortable thing for management to do is to discipline the last person involved; the nurse, doctor or pilot receives punitive action as a result.

The hard thing to do is to get to the true root cause of the issue.

Why did the person make the mistake that resulted in a near hit? Perhaps they were not adequately trained in the procedure. Indeed the process itself could be unfit for purpose. The staff member might have been working for many hours without a break. They could have been experiencing personal issues at home, with a sick or dying relative, distracting them from the task at hand. We know of one recent case where this was a major factor.

In the long term, it saves you money to take the hard option and tackle the system issue which may be indicated by the hidden mass of the iceberg, floating below the surface.

So please report near-misses or as we say regard them as near-hits. The message for managers is please encourage reporting and respond with compassion for the reporter. The bulk of the iceberg represents a threat to us all.

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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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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 & 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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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:

- - - - - - - - - - - - - - - - - - - - - - - - - -

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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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.


Human Factors Principles + Improvement Science = Better Outcomes

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

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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