Making Tomorrow’s Doctors Safer
Patient Safety – the human factor
Martin Bromiley
Accidents were an unfortunate but accepted risk
or complication of flying.
We know we’re not perfect...
But among the flying community it’s
generally believed that ALL
accidents are preventable
But among the flying community it’s
generally believed that ALL
accidents are preventable
....but why do we believe that?
• Investigation (technical & non-technical/HF)
• Investigation (technical & non-technical/HF)
• Safety and human factors embedded from the
very first flight
• Investigation (technical & non-technical/HF)
• Safety and human factors embedded from the
very first flight
• Continued process of knowledge, examination
and assessment of technical and non-technical
skills (Pilots, Cabin Crew, Engineers, Air Traffic
Controllers.....)
• Investigation (technical & non-technical/HF)
• Safety and human factors embedded from the
very first flight
• Continued process of knowledge, examination
and assessment of technical and non-technical
skills
• Reinforcement of the skills to balance safety and
productivity
But it’s much more than just what
the frontline are taught and what
they do.....
It’s also about.......
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Leadership and personal example
Rules that don’t encourage rule breaking
Equipment reliability and design/ergonomics
The whole team understanding of safety and
human factors, relevant to their field
If we understand Human Factors….
We can develop techniques to optimise human
and system performance using:
• Physical design of structures, tools, buildings etc
• System design of process and protocol
• Cognitive strategies for how we behave
In other words, making it easy to do the right thing
all the time, with reliability of outcome
So to understand the human in the
system, future doctors need to
understand….
...fundamentally, that error is normal!
• How design and environmental factors influence
performance
• How systems encourage or discourage doing the right
thing
• The impact of our behaviour on others and vice versa –
and how we really behave!
• Cognitive strategies for behaviour and thinking
• Past investigations and the cost of being unsafe
• The safety v productivity dilemma
Some of the CHFG “Team”over
the last 4 years….
• Prof Jim Reason – Univ of Manchester
• Dr Jane Carthey – HF Specialist
• The late Prof Helen Muir – Cranfield
• Prof Rhona Flin – Aberdeen University
• Tony Giddings - Former member of the
Council of the Royal College of Surgeons Eng
• Nikki Maran – Scottish Clinical Simulation
Centre
• Peter McCulloch – QRSTU Oxford
• Linda Watterson – Royal College of Nursing
• Allan Goldman – Consultant Intensivist
• Mark Emerton – Orthopedic Surgeon
• Jane Reid – President, International
Federation of Perioperative Nurses
• Stephen Ramsden – Chief Executive L&D
NHS Trust
• Chris Sadler – Consultant Anesthetist &
Director of Barts and The London Medical
Simulation Centre
• Dr Melinda Lyons & Bev Norris – HF
Specialists representing the NPSA
• Clare Bowen
• Matthew Sargeant – Hywel Dda Health
Board, Consultant Psychiatrist
• Cate Quinn – Care Quality Commission
• Prof Charles Vincent – Imperial
• The late Dr Karen Woo - BUPA
• Hugh Rogers & Nikki Davey – representing
the NHS Institute
• Simona Arena – Health Foundation
• Prof Nick Barber – Prof of the Practice of
Pharmacy, Univ of London
• Emma Stanton – BAMMbino
• Sir Ian Kennedy – Chair of HCC
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Consultant Anaesthetist
Consultant Anaesthetist
ENT Surgeon
Senior ODP
ODP
Recovery Nurse
Recovery Nurse
Thank you……want to learn
more about HF in healthcare?
• Charles Vincent & CPSSQ at Imperial are
hosting the second “CHFG Open Seminar” on
19 April 2011. Spaces are free but limited, see
www.chfg.org