Mental Health 2013 Conference

Atrainability is the Main sponsor for Mental Health 2013 Manchester March 14 
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.
Zero Tolerance on Error
What stops experienced medical staff caring?


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Wednesday, 04 August 2021

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