Sample Sidebar Module

This is a sample module published to the sidebar_top position, using the -sidebar module class suffix. There is also a sidebar_bottom position below the menu.

Sample Sidebar Module

This is a sample module published to the sidebar_bottom position, using the -sidebar module class suffix. There is also a sidebar_top position below the search.
Blog

Search our Site

Atrainability Blog

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

Sharing the Learning

I had never really thought about situational awareness in the past. I'm a pharmacist myself. I know that I've made mistakes. None of my mistakes have been life threatening; in fact, they've probably been near-misses, but this (course) made me think about how situational awareness affects the way we do things- Julie Jones, Birmingham Healthcare NHS Trust

Atrainability has provided Human Factors training for over 14 years and during that time our team has spoken to lots of people at various stages in their career, and across a range of different disciplines.

We've always been grateful when participants are open about sharing their learning experiences with us. One thing that seems to occur often is that during or shortly after the training sessions there is a moment of clarity when dots are joined and suddenly that person understands how and why those near-misses happened and more importantly what they can do to avoid future errors. There are many stories we could share, but here are a couple :

I was talking about having compassion for patients as well as colleagues on a course recently, and a Dental Surgeon who was attending said: "Quite a lot of patients are just awkward with unrealistic expectations" he went on to say that he'd received a significant number of complaints and some claims. I asked him if this was just something which he encountered or did his colleagues also find the same? After the course, he thanked me and said that moment had made him realise he was perhaps playing a part in the problems he was experiencing, and he would be more aware of his communications with both patients and colleagues when he returned to work. – Trevor Dale

During the coffee break of a course I was running an F2 Doctor approached to thank me, and explained the Situational Awareness module was a light bulb moment for her. During a night shift, she had a difficult hand-over at a time of high workload. The nurse had handed over a patient with a verbal description of a dosage of a respiratory drug, there was a mistake made but the Doctor was clear of the dosage in her mind. The Doctor was working very hard and so did not acknowledge the dosage handover to the nurse. She told me she now understands why she did not read back the instruction. She was stressed and her speech had been degraded due to an overload of information. Although she was cleared of any wrongdoing, she was troubled why she made the mistake. The Doctor was delighted to understand that her mistake was just an indication of her human fallibility; not incompetence, and that now she felt she had the tools to help her avoid repeating that error. – Matt Lindley


As you may be aware, Atrainability has been running Human Factors Open Courses this year at key locations in England. We can't promise Light bulb moments for all, but we can promise a course which will help you find solutions and gain a greater awareness of how you and your teams' behaviour, communication, leadership and briefing and debriefing skills can improve outcomes for everyone. 

If you can't make the dates listed on our Open Course page, or if we haven't announced new dates yet, do get in touch to discuss how our bespoke in-house courses can help your team. 


Trevor

  3319 Hits
  0 Comments
3319 Hits
0 Comments

The Remarkable Truth about 'People Stuff'

​If you ask the question "What makes a difference to your every working day?" and other than the weather, your IT systems and somewhere to park your car, you begin to realise that everything else is about PEOPLE.

So if 'people stuff' has the most impact on your performance, how can we ignore it? Human Factors may be considered a 'buzz word' for some, but the fact is; it's an unavoidable part of everyday life. If you gain an understanding of why colleagues and patients behave the way they do and understand why some communications turn out to be 'Chinese whispers' you can also gain insight into why some of your processes are failing and what you can do to avoid repeating mistakes. This is why Human Factors is so important.

I recently had a morning session with the board of an NHS Mental Health Trust, where they have been fortunate to apply for and gain funding for a coherent training programme to embed Human Factors principles in their organisation.

Virtually all of the Board were completely unaware of the term 'Human Factors', what it meant and of course how important it is to ensure the safe, effective, efficient performance of their Trust.

There are still many organisations that are seemly unaware of the crucial importance of factors that affect their Front Line staff and in fact everyone in the organisation. Notwithstanding the publication of the HF Concordat ( link -  https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-hum-fact-concord.pdf ) in 2013.

We have helped a number of NHS and private healthcare providers improve their performance and the CQC positively encourages Human Factors initiatives. We are very keen to come and help your organisation be it already successful or indeed in need of some improvement or help. All of our work is bespoke and our experience stretches all the way across the entire health and social care spectrum from acute through to community and primary care.

Don't ignore your 'People Stuff'. People are the lifeblood of your organisation.

Trevor

  3799 Hits
  0 Comments
3799 Hits
0 Comments

More of the same? Don’t limit yourself

​The New Year: a time of self-analysis; looking back and looking ahead. 'New Year, New You' is an overused line that you will probably see almost everywhere.

So here's our piece of advice. Let's look beyond ourselves and reflect on your teams work environment too.

If we concentrate on our model of Whirlwind Debriefing – what is one thing we do well? What is one thing we could do more of or indeed less of ?

In general it is accepted that few of us emphasise our successes and share what we do well. Let's try and change to doing that.

That doesn't work for us

In aviation it is mandatory to have an in depth initial course with each new company that a crew member joins and by international law it must be refresher trained and assessed 2 or 3 times a year. Even then our human frailty and fallibility is still susceptible to error.

Human Factors training is about transforming behaviour to create safer more efficient staff. You cannot completely error-proof the human but you can provide the right training and support to give them the best chance to get it right and be safe under quite trying and stressful conditions.

This can't always be achieved in one brief intervention. In order to see noticeable effects your team should be allowed the time to fully digest the learning points from the training sessions and attend refresher sessions so that they can begin to embrace a new way of thinking.

Make achievable targets

Do you want your team to be part of the solution? We don't need to tell you that motivation is one of the first steps to making positive changes.

If you're struggling to make a New Year's resolution that's achievable for you and your team, here are a few suggestions:

This year we will:

  • Gain the confidence to raise issues
  • Be more motivated and effective
  • Find long term solutions to recurring issues and everyday challenges

Once you've decided on your resolution, we can help you stick to it.

Start your team on the journey to a successful New Year...

We offer help for individuals and small teams in the form of Open Courses click here to visit the page on our website. We can also provide training and support for departments and larger teams click here.

  3391 Hits
  0 Comments
3391 Hits
0 Comments

Safer Solutions that support staff relationships

​One of the most popular subjects when we talk about Human Factors is the understanding of behaviour and personality types. The differences in how individuals react and see things especially in high stress, high risk situations can result in a strong team but sometimes they can cause misunderstandings or communication errors.

The relationship between team members is an important one. If individuals feel secure and supported within the team it will promote better communication and reporting long term.

" The importance of everybody having a say in safety situations and feeling able to speak up "
 - Mr Andrew Aldridge (BMI Eastbourne, June 2015)

" We have the right to make mistakes and learn from them "
- Erica Rapaport (SAS Ipswich, November 2015)

We regularly receive feedback from course participants which highlight how our training helped them to go back to work and find solutions to what seemed insurmountable problems.

Understand the facts

Understanding Human Factors principles better will help you recognise the facts underlying human behaviours and stresses. This includes identifying stress in yourself and others and using techniques to remain calm in stressful situations; enabling you to be more aware of your own behaviour and see other persons point of view.

Put aside hierarchical barriers

Intimidation and fear of reporting errors can lead to recurring problems. Human Factors training can equip you with the ability to cut through whichever side of the hierarchical barrier you are on. This will help your team to maintain a focus on safe, compassionate care for colleagues, patients and relatives, which is the upmost priority.

Don't skip on the briefing and debriefing

We can't stress the importance of these enough. Briefings and debriefings will ensure better communication between staff, more detailed handovers and give staff the support and confidence to raise issues, which will help to reduce unnecessary errors. Furthermore debriefings are a simple, often underutilised aspect of learning from success and near-misses. Our training will provide you with the skills to ensure you create the opportunity to maximise team-working during this time.

Promote learning, avoid inappropriate blame and make your team more effective

Communication and behaviour can be an ongoing challenge. Our Human Factors Open Courses are the perfect introduction for both front line staff and managers who want to improve communication, enhance performance and increase safety. Discounts are available for early bird bookings. 

If you can't make the dates listed on our Open Course page, or if we haven't announced new dates yet, do get in touch to discuss how our bespoke in-house courses can help your team.

  4185 Hits
  0 Comments
4185 Hits
0 Comments

How can we help minimise errors in Child Protection?

​What does safeguarding have in common with flying Boeing 747s? Well in terms of why things go wrong, perhaps more than most people realise.

No matter what walk of life you work within, human fallibility interferes. A brief examination of many serious case reviews shows comments about missed signs of abuse, missed opportunities to intervene. The recent SCR into Levi-Blu Cassin refers to serious failings and 'professional optimism' http://www.bbc.co.uk/news/uk-england-birmingham-34416644 . Professor Eileen Munro in her report subtitled 'A child-centred system' published in May 2011 wrote "errors and mistakes should be accepted as to some degree inevitable and to be expected, given the complexity of the task and work environment."

Of course it is never quite so easy to spot things when perpetrators are concealing the harm. Consider Baby P where his Mother concealed his facial bruising under chocolate. Furthermore the paediatrician who examined him before his death had not been told he was on a child protection plan. This was an apparently simple communication error that had immense consequences because she was not aware of the background.

Very few of us work with colleagues who intend harm, but error is rife. Much of it is due to our being asked to work in ways which we are simply not designed for, such as extreme workload, interruptions and distractions. Also this case as I write http://www.bbc.co.uk/news/uk-england-somerset-34547660 demonstrates the importance of shared information to build Situation Awareness. The police failed to pass on vital information that the father had a relevant record of domestic abuse. Situation Awareness is a crucial concept referring to the 'mental model' we all have of what we are expecting now and what happens next. When this conflicts with what we see and experience there is clearly a problem.

There is a potential danger sign anytime you hear yourself or others say "Oh, I thought this or that was what we are doing" or perhaps "I am seeing this and you are not". There are classic signs that Situation Awareness is being lost, such as conflict between 2 sources of information. However to simply blame 'being human' is not good enough for the professional. To us it is incumbent to recognise how and why we all make mistakes and adopt methods that help keep us, our colleagues and our clients safe.

These non-technical skills are well understood and can be trained and coached. They encompass social skills such as Leadership, Followership, Cooperation and Management of others and cognitive skills of Situation Awareness and Decision making.

The culture is also riddled with blame, but what does it achieve? High reliability organisations recognize blame is mostly inappropriate and counter-productive. If it drives near-miss and error reporting underground it is useless.

The frontline teams know where the barriers to safety are, which procedures are not fit for purpose and where communication blocks occur. Their reports should be welcomed, responded to and acted upon. This is how commercial aviation has become safer and it can be adapted to safeguarding. Atrainability offers training solutions to address these issues.

Trevor Dale, Atrainability


  3695 Hits
  1 Comment
3695 Hits
1 Comment

Human Factors – no longer an option

​The publication in September 2015 of the National Safety Standards in Invasive Procedures is a major positive move. http://www.england.nhs.uk/2015/09/07/natssips/

Dr Mike Durkin, NHS England Director of Patient Safety, said: "This is the first time that national safety standards have been set and endorsed by all relevant professional bodies". These include the royal colleges, the Care Quality Commission, the Nursing and Midwifery Council, the General Medical Council, Monitor, the Trust Development Agency, and Health Education England.

Dr William Harrop-Griffiths, Consultant Anaesthetist at Imperial College Healthcare NHS Trust and chair of the group that developed the standards, said: "The NatSSIPs contain 13 key standards which cover all aspects of the patient journey throughout an invasive procedure, ensuring safety checks are performed by the team providing care at every critical step in the pathway."

"However, this work is not just about establishing a network of safety checks. It is about ensuring that safe care standards are harmonised both within and between hospitals, and that learning from the development of local standards based on these national standards is shared by all."

Now good Human Factors practice is no longer an option.

Indeed the GMC has recently run its own online discussion document focussing on Human Factors which will undoubtedly have a bearing on future accepted practice.

There is nothing new here, but just giving it the official stamp of approval makes a huge difference, especially by all the professional bodies. This is fantastic news and a real step change, at last. Now comes the challenge of how to ensure such good practice is adopted effectively, not just lip service.

Classroom teaching to raise awareness and understanding of Human Factors is the starting point as used to great effect in other high-risk, but resilient professions like aviation, but how do we embed the learning long term? E-learning certainly has its place in supporting and cementing knowledge, but is unlikely to create behavioural change in isolation.

By and large people learn through experience, through being able to put theories and practical tools into practice day to day, and the culture of an organisation has to support that learning.

The major point is that people have to want to change the way they do things. Coaching and mentoring can certainly help. Those organisations that have invested in training and role-modelling from the top have achieved high performance that has sustained. They are beacons for effective care.

These new standards are currently aimed at invasive procedures, but it cannot be long before all of Health and Social Care formally recognises the critical importance of safer working behaviours.

Atrainability have been a leading provider of Human Factors Solutions to the healthcare industry for well over a decade, with over 100 years of training experience in our delivery team across a range of safety critical/high performance industries. Many NHS Trusts and private providers have already recognised this and to we have trained thousands of professionals across the UK.

Atrainability offer a range of training and coaching options

  • Trust-wide programmes that are designed to cover all departments and embed safety Champions and train the front-line teams and individuals. This aspect also covers leadership specialised courses and Master-classes and supportive coaching
  • Train the Champion courses, minimum two days, ideally three or more. They offer an in-depth understanding of Human Factors principles and the tools and skills that help the front line teams to work safe. The by-product is sufficient understanding to look into Root Cause Analysis to see beyond what people did but to look into why
  • Human factors awareness modules for front line teams that can be delivered throughout the year in modular design
  • Supportive work-place coaching to cement the knowledge and skill.

As many of you know psychopaths are thankfully rare in health and social care but human fallibility is a given. Long term safety enhancements come from knowledge and demonstrable skills. We are here and ready to help.

Trevor Dale.

  3568 Hits
  0 Comments
3568 Hits
0 Comments

I could have told you that

Many high-performing professionals make their job look easy. Well maybe not micro-surgery but aviation is a good example that it seems is widely misunderstood. I hear many people say "you pilots don't understand – we deal with sick people who aren't OK when we start treating them. You wouldn't get airborne in a plane that wasn't OK" 

Well pretty much of course not. But if only life were that simple! Pilots and for that matter cabin crew, are there for emergencies, generally unanticipated, often at periods of low arousal. Look at Kegworth – 1989 - routine flight Heathrow- Belfast - relaxed take-off and climb and suddenly an engine breaks apart. The crew, who must have been terrified, misidentify the problem and shut down the wrong engine. 47 people die.

Lessons learned? Well it is an imperfect World and the same essential error happened in Taiwan in January 2015. You will probably remember the horrific images of the plane with wings vertical crossing a bridge before plunging into the river killing 43. The error was the wrong engine shut down again.

However we all now accept that flying is significantly safer than any other form of transport taking into account the number of flights per annum. Things do go wrong but what helps prevent tragic potentially fatal accidents is training and preparation. Especially thinking ahead and discussing what could go wrong and having a plan in place for how it would be handled if it did. Think Captain Sullenberger and crew and the Hudson River successful outcome.

How often have you said with hindsight "I could have seen that coming" or "I could have told you that would happen"? Experience is a great learning tool but trial and error is simply not acceptable.

That seems to be what healthcare is doing though. There is still a general reluctance to learn day to day success, failure and near-misses.

This is what Human Factors training can aid such as how to share plans across the team and encourage input from everyone who might spot the impending threat and intervene for safety. Even more so when it comes to post-hoc debriefing discussions about what worked well and what could be improved.

When you get down to it aviation and health and social care is about risk management. Risk management is about Human Factors. Mental preparedness and appropriate hierarchy and open communication.

  3543 Hits
  0 Comments
3543 Hits
0 Comments

Inappropriate hierarchy and what to do about it

BBC Radio 4 - From the Cockpit to the Operating Theatre

Why lessons learned from aviation psychology are starting to save lives in hospitals.

​Matt Lindley, trainer and coach with Atrainability, featured in a radio broadcast recently on the BBC, alongside Prof Rhona Flin and other eminent healthcare experts, speaking about the problems of dealing with inappropriate hierarchy when it comes to safety. 

Matt's background is Royal Air Force and now British Airways where he flies long haul around the World. He has an extensive training experience which for the most recent few years has expanded into Health and Social Care with Atrainability.

Clearly both military and commercial aviation enjoy the benefits and problems associated with hierarchy. Both have developed tools to try and get the message through when safety is paramount. In my case, starting flying in 1971, the hierarchy or Authority Gradient was a real problem. Captains were never called by their given name, but always 'Sir' or 'Captain' on and off the aircraft.

Just to explain the concept of the Authority Gradient this is the view from the top person versus the view from the junior. If you ever hear someone say "I could have told you that" the immediate question must be "why didn't you?" or perhaps "what is it about me that stopped you?"

How many of us believe we are very approachable but then find one of our team has hesitated to challenge what we are saying or doing? I've been there and it is a terrifying bit of personal feedback. In my case I was a Training and Checking Captain with real power over other pilot's futures. I was the veritable scary monster that triggered fear – irrational I hope, but perceived real in the moment nonetheless.

The one advantage aviation has, of course, is the 'Black Box' – real evidence of what was said and done. Thus we know that the various Human Factors are a problem. It is often said that 90% of air crashes someone is heard to voice concerns but not effectively enough to stop the ensuing accident. Aviation works very hard to deal with this and effective balanced assertiveness, perhaps using a 'Trigger' word to get attention.

We teach these techniques in Health and Social Care supported by coaching in the live or simulated workplace to get to those who, for whatever reason, find class too difficult to attend!

So the responsibility lies throughout the team – the leaders, recognising that they may not be as approachable as they think, should encourage appropriate questioning. Those more junior in status should never assume and always accept their role in checking the correct process is taking place. 'Trigger' words work very well in health and social care too. "Gorilla???"

Our Human Factors Open Courses are the perfect introduction for both front line staff and managers who want to understand how they can improve issues such as inappropriate hierarchy, among others. Discounts are available for early bird bookings, but please do get in touch if you'd like a more bespoke, in-house traininig soultion for your team. We'd be happy to help you.


  4592 Hits
  0 Comments
4592 Hits
0 Comments

Human Factors Training – Published evidence that it works!

We all know how challenging it can be to find good quality hard evidence that training teams and leaders in Human Factors awareness and skills enhances Patient Safety. Health Education England are seeking such evidence now for all forms of training. Quite right too. We have worked with various teams over the years notably at the University of Oxford with varying degrees of success. There are a plethora of published papers out there with our names on them. One of the arguments has been what to measure and I believe firmly that the only real measure is patient outcome. We have taken part in other recent research and I am led to believe that some further positive results will shortly be published. 

Some of you who have been with us a while will know that we were invited in to Newcastle Neurosurgery unit by Patrick Mitchell, the clinical lead, in 2006 where after some in-house training they had reduced the wrong-side error rate for cranial and spinal procedures dramatically (from 1 in 300) but then had a recurrence. 
The training consisted of putting all the direct theatre team and their immediate leaders through a one day interactive training course in understanding the problems around human behaviour and fallibility and practical solutions. This was supported by coaching to help embed the skills in practice. I think it is fair to add that two senior team members found it difficult to attend.
The result is now over 5 ½ years without a side error from a pre-intervention rate of 1 in 300! That is over 21,500 sided procedures in the unit with essentially the same entire team, although one of the senior clinicians did leave a couple of years ago – to concentrate on private practice.
 
The results have been published and is available to download freely - Click here to view full report in PDF format
 
I don’t believe it is unfair to say that the fundamental issues were around behaviour, especially team briefings and checklist discipline. Incidentally this was before the WHO checklist was published. Patrick Mitchell is a private pilot himself and has a clear understanding of the importance of checklists in safe performance. 
I would like to emphasise that the Atrainability team didn't achieve this –we simply helped the front-line team to build and maintain the confidence and skills to deal with the problems successfully. 
We encourage all our clients, colleagues and prospective clients to continue to seek and share evidence and best practice to improve Patient Safety for everyone. 
The Atrainability team are of course, very happy to explore further opportunities to develop solutions to human error, poor behaviour and help teams avoid avoidable harm.
 
  5080 Hits
  0 Comments
5080 Hits
0 Comments

Human Factors are not just for Christmas

The Festive Season is upon us again and thoughts turn to gifts. What finer gift than support for a Human Factors Training programme?

 

It is apparent that the importance of Human Factors training across all workplaces is being recognised after all this time. How pleased Martin Bromiley must be.

One of the most pleasing changes this year has been the growth in organisations that realise that short interventions are a waste of effort and money.

You don’t change the culture (whatever that means) with a few hours of classroom chat about how to avoid errors.

This year has seen a number of NHS Trusts and private healthcare providers come to us and ask for programmes that address deep-rooted issues. We have started programmes of in-depth training of managers and team leaders to help enable them to understand the flaws in the processes and procedures that their staff have to deal with - the error-provoking conditions under which the front-line staff work. These are the holes in the Swiss Cheese models!

One of the delightful comments we received was from a middle manager in a mental health Trust who had performed a disciplinary procedure quite differently after an Atrainability course. She said that beforehand the staff member would probably have been sacked for violating procedures. But she then realised that it had been done with the best interests of the service user in mind. There was no desire to harm, no malice. So they have kept their job, albeit with a comment on their personal file, but the lessons are shared with others. A palpable shift to a ‘Learning Organisation’.

I know the aviation comparisons are sometimes overplayed but please bear in mind that Human Factors are taken seriously enough that by law they must be refresher-trained each year. Once a foundation knowledge and understanding is embedded within the organisation, refreshing and updating is comparatively easy.

So like the proverbial puppy, Human Factors is not just for Christmas it is for life – literally!

May we at Atrainability wish you all a very Happy Christmas season and a safe, effective New Year.

 

  4103 Hits
  0 Comments
4103 Hits
0 Comments

We promote what we tolerate.

It was very good to see so many old friends at NAMEM (National Association of Medical Education Managers conference) recently and particularly put faces to those names!

What will probably stick in all our minds was the talk by Dr Victoria Bradley on her culture-changing experiences and her successful challenge of an unsafe clinical department situation. It was a pleasure to hear that her bold actions brought real front-line improvements in staffing levels and patient care.

She had to overcome her concerns about ‘whistle-blowing’ and potential repercussions and having done so was rewarded and thanked by very senior management in her Trust. Quite right too. But sadly this is not a frequent occurrence regarding the happy ending.

Frequently we hear course delegates stating that they don’t feel confident in raising concerns and in some situations don’t feel anyone is listening and nothing will change.

However how does this fit with duty of candour? We promote what we accept and tolerate. Turning a blind eye is simply not professional.

However the multiple reasons why so many of us don’t challenge unsafe or unprofessional situations are understandable and often a facet of our very essence of being human, such as the Fight, Flight, Freeze response. We have recently run several courses when admissions of passive behaviour have been manifest. But we at Atrainability have found we can help rebuild that confidence and re-motivate team members to speak up with appropriate persistence.

Courses combined with individual and team coaching helps build more-effective safer team-working. We are constantly developing new material, with a focus on advanced Human Factors looking at Stress Solutions and dealing with difficult people – including colleagues!

 

 

  624 Hits
  0 Comments
624 Hits
0 Comments

Human Factors - common sense made conscious

We have begun a major training programme at a large private healthcare provider in London where all staff are attending an initial very short introductory module on Human Factors. 
The content is limited to why the subject is relevant to them all, some explanations of why we are all fallible and a few practical takeaway tools on how to try and avoid things going wrong. The long term plan is to continue to work together and build a sustainable high reliability organisation with safety at its core. 
Later in the Autumn it will include training trainers and champions to embed safe policies and procedures and seek to support staff.
The Director of Nursing had been actively seeking such training and has been a fantastic advocate, but the clincher was getting to present to the Board. 
The Chief Executive is a smart no-nonsense lady. I asked her and her senior colleagues if they knew what Human Factors is. Her instant response "well it's just common sense". Of course it is, but the trick is how to bring that to the conscious brain when faced with all the pressures and hazards of everyday work life.
That is where we seem to be helping judging by the feedback from the attendees. They love the simple messages and that we are talking their language.
Mind you it's quite a challenge with each class containing up to 30 from every area in the Hospital from finance through reception to ITU and theatre teams.
It is fun, engaging and at first sight seems to be making a tangible difference. 
Here is an example of unsolicited feedback from an ODP in paediatric theatres:
 
"I just wanted to say how much I enjoyed the training session. I think Ben delivered a really good session and I personally learned a great deal. It has given me some good ideas of ways we can improve our day to day practice within our department and has inspired me to look further into the human factors training principals and background.
If you could pass my thanks on to him that would be appreciated."

The icing on the cake, though, is that the Executive Board are all attending alongside all the 600 staff. 
Now that shows what leadership should be and will undoubtedly have a profound positive effect.

  5102 Hits
  0 Comments
5102 Hits
0 Comments

Reporting Near Misses - Untoward Incident or Known Complication?

The benefits of reporting near misses are surely beyond dispute. Each close shave is a learning opportunity which should be shared with others. Does every doctor need to experience problems first hand and patients endure possible harm in order to gain a high level? 

I have recently heard of an incident in maxilla-facial surgery which has disquieted me. A senior consultant decided to perform two lengthy operations in one day and incur a significant overrun to the detriment of the theatre teams. It had been possible to ask a fellow senior surgeon to take on one case and indeed such an offer had been made. The offer was impolitely refused.
The second procedure was commenced at 4 pm and involved a neck dissection. Unfortunately a small tear was made in the lower end of the jugular vein where it joined the subclavian vein. The anatomy was non-normal in that the vein was above the clavicle rather than under.
 
There was considerable haemorrhage which was not controllable. Vascular surgeons were called and the vessel was approached from the anterior chest wall, but were unable to control the bleeding. Eventually orthopaedic surgeons were called to divide the clavicle and the tear was over-sewed. The patient lost 18 units of blood and the cell-saver was used successfully to replace lost blood. The anaesthetist performed very well in difficult circumstances.
 
What could be learned?

The surgeon did not consider this a reportable incident and indeed was most vociferous in wishing it not to be reported. One must ask why? Does it indicate fear of the local culture? Or is it something more ego-driven?
 
What would you consider the professional response?
 
Surely if this is a recognised non-normal anatomical situation it should be shared to help junior doctors learn to avoid it happening to them?
 
How can we make it ‘safe’ to report near-misses and move the whole culture closer to the aviation model where incident reporting is actively encouraged? 

We specialise in training for debriefing to learn. Blame serves little useful purpose unless people are wilfully ignoring rules and due process.
 
Training utilises the greatest resource – a team member who may have made a mistake despite trying their best not to. What a resource to help the whole organisation learn! Shame to waste it.

  6970 Hits
  0 Comments
6970 Hits
0 Comments

Lighting the Blue Touchpaper

Lighting the blue touch paper

The trainers are excellent, engaging, knowledgeable and enthusiastic. The Training was brilliant and it has really set fire to my personal blue touch paper. It has made me think about how to look at things differently, and as a result I revisited a policy I am working on; so that lessons learned can be applied in a more meaningful, informative way, rather than staff feel they are being blamed and penalised.

Project Lead, Safe Services, Cheshire and Wirral Partnership Foundation Trust

This was feedback from this week when we presented a train the trainer course for Cheshire and Wirral Partnership Mental Health Trust. This is the second in a series aiming to bring about sustainable improvements in a Zero Harm campaign. Other selected comments from the evaluation sheets:

 

·         Very eye-opening course which used common-sense ideas & delivered them in a structured constructive manner

·         Thoroughly enjoyable & thought-provoking. Ought to be part of mandatory training

·         Need more staff from clinical area to attend this training to enhance knowledge, practice, empower them.

·         Hope the Trust fully embeds this learning into the culture

·         Excellent course – pragmatic, common sense & gives words to describe how I feel about potential change culture

The initial response has been fantastic.

 

At the end of Day 1 one of the delegates from the first course spoke passionately of the changes she now felt able to make. She really enthused her colleagues.

Most startling and pleasing was to hear from her how what had begun as a disciplinary inquiry became a lesson in learning and understanding the good reasons why a staff member had deviated from procedures in efforts to do the best for the patient or service user.

We offer a flow chart based on that of Professor James Reason that clarifies when training is the correct treatment for rule violations and those rare occasions when disciplinary action is necessary.

In simple terms if you are not employing psychopaths or sociopaths in your teams, then most errors are unintentional or made with good outcomes in mind.

Understanding why and how errors are made at the Human level is so beneficial to creating a resilient high performing sustainable system.

It could even mean a redesign of some procedures. Many of our clients are doing that now.

If it results in a reduction in avoidable harm it must make sense!

  4533 Hits
  0 Comments
4533 Hits
0 Comments

Real positive change at the frontline

The Patient Safety Congress is in Liverpool this week, and the subject of Human factors is to the fore. Back at the front-line we are delighted to report that feedback from nursing staff at one department we have recently trained has reported real improvements in team practice and hence morale -

"Since we attended the Human Factors course, we now, as a department have daily meetings to discuss ‘job’ allocation, so that everybody is aware of what is expected of them during the day. This is working particularly well, everybody is now focussed on what they need to do, rather than overlapping, and tripping over each other,

We also have a  debrief at some point in the day, to ensure everything is  still running smoothly, and talk about any problems or situations that may have arisen through the day. All the nursing staff are very happy implementing this, and wish as a group to say thanks again."

This was a result of a whole department enjoying a full day of class-based training consisting of:

Ø  Introduction to Human Factors

Ø  How & why we make errors

Ø  Situation Awareness

Ø  Decision Making

Ø  Communication

Ø  Dealing with difficult people

Ø  Leadership & team-working

Ø  Briefing & Checklists

Ø  Debriefing for Learning

It was a full day but enjoyable all round. Not bad when you consider it included the whole range of staff from clerks, reception staff through nurses and ophthalmologists! Phew.
  4634 Hits
  0 Comments
4634 Hits
0 Comments

Safety in Neurosurgery - a successful Human Factors intervention

 
Five years have now passed since the Atrainability team helped a neurosurgery unit in the North East of England overcome a string of major wrong side errors. 
Prior to our training and coaching intervention their had been a rate of 1 in 300 wrong side errors. The surgical Lead had instituted a 'knife' check - a check that everything was as it should be pre-knife to skin - but then another error occurred.
 
Atrainability trained almost all the team members in how to avoid and trap errors and particularly how to assert the need to brief the team and check all appropriate items, including of course surgical site. One or two senior team members were unable to attend but those who did were trained in dealing with colleagues who were not keen on such non-technical matters, politely but firmly.
This was all before the WHO checklist had been mandated.
The result is now five years without another incident. Time between error is the measure and is statistically valid.
 
It is a sad fact that many organisations contain 'difficult' people who feel their skills are being questioned. Not everyone is open to comments about their behaviour. It is not an accepted part of the culture in many areas of healthcare. But if the team stand united and firm, challenging individuals can be handled without any unpleasantness. 
 
Although not part of an academic randomised control trial, these results are notable and a splendid testament to what can be achieved in the name of patient safety.
 
As the Surgical Lead said - "The error you have to prevent is 2 years from now, out of hours, when you are on holiday and a locum surgeon you will never meet is operating at night with a junior anaesthetist and newly appointed scrub nurse."
 
For those still sceptical, consider the cost of training against the cost of compensation and litigation. It is an investment well worth considering.
  4746 Hits
  0 Comments
4746 Hits
0 Comments

Debriefing? Missed opportunities to learn from near misses.

The accepted theory of Threat and Error Management 1,2  indicates that there is tremendous benefit to safe teamwork  by attempting to avoid all possible problems in advance. From this has come the practice of team briefings before surgical procedures. However not everything can be foreseen and our memories of what has been discussed may be erroneous due to such as the passage of time, fatigue, hunger, personal stresses or just ineffective communication. For this reason the WHO Safer Surgical Checklist has been mandated and its use is accepted across healthcare surgery. However it seems from our experience that compliance is less than 100%. One of our Atrainability team has just had an operation where the WHO paperwork does not appear to have been completed and performance of the checks themselves somewhat suspect. Fortunately no harm has apparently occurred.

However the greatest opportunity for improving safety is a simple debrief. The front-line team are the most under-utilised source of learning from success as well as failure.

A recent investigation of a particularly tragic case highlights the resistance to learning from everyday events. Our team was taking part in a research project in a major hospital in 20083. A scrub nurse taking part in a neurosurgical procedure was asked to hand the surgeon a syringe of saline to wash out the operating site in the cranium of a child. The surgeon did not remove his eyes from the microscope and did not check the syringe. It so happened that the nurse was under training in this specialty and had mistakenly handed a local anaesthetic. Fortunately the error was trapped by the supervising scrub nurse who handed her the correct saline. Both syringes were externally identical – no colour-coding. The Consultant surgeon was completely unaware, but the Anaesthetist was fully aware.

Within 2 years of this a tragic but similar incident occurred in the same hospital. http://www.bbc.co.uk/news/uk-england-london-25916336

At the time of our observation the Consultant Anaesthetist declined to debrief with the team because "nothing happened".

No direct conclusion can of course be drawn but overcoming resistance to learning from near misses (near-hits?) should be a professional response.

Encouraging debriefing and responding appropriately to warnings of unsafe situations, avoiding unnecessary blame, must be the way forward for management and multi-disciplinary teams.

References:

1) On error management: lessons from aviation - Department of Psychology, University of Texas at Austin, Austin, TX 78712, USA Robert L Helmreich professor of psychology helmreich@psy. utexas.edu BMJ 2000;320:781–5

2)     Culture, Error, and Crew Resource Management Robert L. Helmreich, John A. Wilhelm, James R. Klinect, & Ashleigh C. Merritt, Department of Psychology The University of Texas at Austin

3)     Catchpole, K, Dale, T, Hirst, G, Smith, P, Giddings, A.(2010). A multi-centre trial of aviation-style training for surgical teams. Journal of Patient Safety 6(3), pp. 180-186.

  5777 Hits
  0 Comments
5777 Hits
0 Comments

The Human Factors Message is spreading

It is great to spread positive news about the growth in adoption of Human factors. Increasingly Healthcare organisations, NHS and private sector are adopting training and process redesign with a view to make care of patients safe by design not by luck.

Atrainability have been engaged to train Trust-wide trainers and Champions in several healthcare providers. Here are some anonymous examples:

·         One of the top-performing Trusts in the NHS in England is offering Atrainability Human Factors Train the Trainer courses to all its trainers – clinical and non-clinical. Almost 50 have attended and we have a waiting list. They are tasked with embedding safe practice and checking procedures for sense and practicality.

·         A major private healthcare hospital has engaged Atrainability to train the entire nursing staff across all wards and units.

·         We have recently worked with a clinical simulation unit and then subsequently with the same Trusts Maternity Unit using advanced simulation debriefing techniques.

·         Training and coaching in a Medical Assessment Unit has revealed solutions to blockages in patient throughput from A & E or GP input to ward or discharge to home.

·         We are working with a Mental Health Trust on smarter procedures and checklist design for such as safe monitoring of in-patients and service users including early recognition of potential slips, trips and falls.

·         A major cardiac centre has engaged Atrainability to help build safer, more resilient teams in the ITU. The same centre has changed Operating Theatre procedures around Briefing, Checklist usage and Debriefing with our training and coaching support.

·         As a sign that the knowledge and skill of safe Human Factors working is spreading we are delighted to be able to streamline the SMART anaesthetics course that we run with the team from the Difficult Airway Society http://www.das.uk.com/course/smart

  4490 Hits
  0 Comments
4490 Hits
0 Comments

Never events and those pesky Human Factors

I’ve recently heard of several recent never events and thought I would share the Human Factors elements as reported to me.
In a Maternity unit a vaginal swab was left in post-delivery and the doctor was  found guilty by the Root Cause Analysis because he had failed to follow standard procedures. But looking at incident in more detail it transpires that he was interrupted by 4 other urgent cases in the unit while trying to deal with this one. The dangers of interruptions and distractions are well recognised and we should all work hard to reduce and ideally eliminate them.
You could argue that this is another side-effect of short-staffing perhaps?
 
The next was about a junior doc who had ignored the Time Out check and had helped himself to local anaesthetic and scalpel behind the scrub nurse. Instead of the trigger finger release planned he went into the wrist as for a carpal tunnel procedure. What was stunning was that this was 18 months ago and I know of an identical error at a high performing Trust 10 miles away – this Summer. It is the responsibility of all the team to ensure correct application of the WHO checklist. Many times we hear of how use of the checks slows down the flow of the day especially in small day case units, but this is what happens if you don’t. No-one would be happy to take off in a plane where the pilots hadn’t checked everything that mattered …..!
 
The latest report into Barrow Maternity unit make unpleasant reading too http://www.bbc.co.uk/news/uk-england-cumbria-25322238. 
‘Insufficient supervision’; ‘inadequate training’; ‘failure to monitor CTG’ etc. Bad people? Maybe but probably a failure of training. Nurses, doctors, midwives are not normally chosen from the ranks of psychopaths, but in order for us all to adopt safe procedures we need to know the rationale. The investment in training pays you back in every way – the human cost – patients, relatives etc; retention of staff due to improved morale and non-acceptance of poor behaviour; reduced cost of case reviews and CNST payments.
 
To find out more about our Human Factors training courses click here.
 
  4996 Hits
  0 Comments
4996 Hits
0 Comments

The Chandelier Principle

I’ve had a great week – 3 days running a train the trainer with Humberside Fire Service and their offshoot HFR Solutions. Our new partnership will help to spread the Human Factors message across Emergency Services and Industry in the Humberside region and beyond. Great team there with imagination and vision, coupled with the energy and intelligence to make a real difference.

Yesterday, December 5 Atrainability exhibited and ran a MasterClass in changing healthcare safety culture.

Today I am off to meet Air France and discuss SportsTec high quality video recording and playback software. British Airways have just bought this for installation in their simulators. It is without question the most fantastic training aid.

In the MasterClass I referred to teams as being the light-bulbs that have to want to change in order to improve safety behaviour.

I just woke early with my own light-bulb moment.

A successful organisation is like a chandelier with long life bulbs. They require less energy, they cost more to begin with, but they last longer. They shine out like a beacon and bring light around them. They work.

A less successful organisation is like a chandelier with many bulbs out. They run old fashioned incandescent bulbs. They fail frequently and the overall effect is dim. They don’t shed much light.

Training is not cheap – up front. But it makes a lasting change. It brings long term excellence that sustains. Successful organisations, be they NHS Trusts or commercial organisations recognise this.

Nothing is so powerful a training aid as watching your own performance and hearing your own words. It helps the light-bulb want to change.

Atrainability can help to spread that light.

  5121 Hits
  3 Comments
5121 Hits
3 Comments