University of Dundee
School of Medicine
Human Factors Science in the
Undergraduate Medicine
Curriculum at Dundee
Dr Evridiki (Evie) Fioratou
Lecturer
Medical School Lead for Behavioural & Social Science
Human Factors Workshop, 2G12 Dalhousie, 18.12.2013
Outline
 Teaching Agenda
 Progress
 Challenges
 Strategic Vision
Teaching Agenda
Teaching Agenda
 Development of Human Factors Science in
the undergraduate medical curriculum
 Integration of teaching and research
 Critical thinking development
GMC’s Tomorrow’s Doctors (2009)
Outcomes To be Addressed by
Human Factors Science Teaching
Ensuring GMC’s Tomorrow’s Doctors
(2009) Outcomes
The doctor
as a scholar
& scientist
The doctor
as a
practitioner
The doctor
as a
professional
Outcomes 1
The doctor as a scholar & a scientist
9 Apply psychological principles, method & knowledge
to medical practice
(a) Explain normal human behaviour at an individual
level
12 Apply scientific method & approaches to medical
research
(b) Formulate simple relevant research question in …
psychosocial science … and design appropriate
studies or experiments to address the questions
Outcomes 3
The doctor as a professional
21 Reflect, learn & teach others
(c) Continually & systematically reflect on practice …
(e) Recognise own personal & professional limits …
22 Learn & work effectively within a multi-professional team
(b) Understand the contribution that effective interdisciplinary teamworking makes
to the delivery of safe & high-quality care
(d) Demonstrate ability to build team capacity & positive working relationships &
undertake various team roles …
23 Protect patients & improve care
(a) Place patients’ needs & safety at the centre of the care process
(b) Deal effectively with uncertainty & change
(c) Promote, monitor & maintain health & safety in the clinical setting,
understanding how errors can happen in practice, applying the principles of
quality assurance, clinical governance & risk management to medical practice,
& understanding responsibilities within the current systems for raising concerns
about safety & quality
Human Factors Science:
Design & Delivery
An interactive and continuously evolving process
Planning
Developing
Implementing
Evaluating
Planning I
 Agreement on key Human Factors topics for
undergraduate medicine*
 Clinical colleagues’ needs assessment*
 Identification of Human Factors topics within
the extant curriculum
 Students’ needs assessment
 Environmental needs assessment
 SSCs
Planning II
Teaching Delivery Methods
 Lectures and workshops
 Individual and Group projects (teaching–research link
is mutually beneficial)
Assessment Tools
 In line with the Medical School: e.g.,
formative/summative, written reports, verbal
presentations, reflective portfolios, as well as
integrated assessment within OSCE, DOPS, miniCEX and CBD
Developing
 Define learning outcomes for: whole Human Factors
programme, SiP and PiP phases, SSCs
 Identify relevant diverse resource materials for the
study guides and the teaching sessions
 Develop case scenarios from different medical areas
with the help of clinical colleagues to instill HF practice
and relevance and to ensure seamless integration (cf.
TDGs: Patey, Fioratou, Friar, & Flin, 2011: AME)
 Develop diverse research opportunities for transfer of
learning from the lab to the medical world (cf. Fioratou,
Flin & Glavin, 2010: Anaesthesia)
Implementing
(albeit fragmentarily at the moment!)
Fundamental Characteristics of
Human Factors
 It takes a systems approach
 It is design driven
 It focuses on two closely related outcomes:
performance and well-being
Dul et al. (2012; Ergonomics)
Progress
Year 1
 Principles Block
Systems thinking
[Clinical human factors skills & IPL]
 Respiratory Block
Integration of systems thinking and clinical human
factors skills
 GI Block (in preparation)
Application of systems thinking and clinical human
factors skills
Principles Lecture
Learning Objectives
 Define Human Factors Science
 Develop an understanding of systems
thinking & its applicability
 Explain the relevance of Human Factors
Science to clinical practice
Human Factors/Ergonomics Definition
Ergonomics (or human factors) is the scientific
discipline concerned with the understanding of
the interactions among humans and other
elements of a system, and the profession that
applies theoretical principles, data and methods
to design in order to optimize human well being
and overall system performance.
~ International Ergonomics Association ~
Definition – Reinforced
“… the theoretical and fundamental
understanding of human behaviour and
performance in purposeful interacting sociotechnical systems, and the application of
that understanding to design of interactions
in the context of real settings”
~ Wilson (2000) ~
Wilson JR. Fundamentals of ergonomics in theory and practice. Applied Ergonomics
2000; 31: 557–67.
Systems Engineering Initiative for Patient Safety
(SEIPS) Model
Carayon P, Hundt AS, Karsh BT, Gurses AP, Alvarado CJ, Smith M, et al. Work system design for
patient safety: The SEIPS model. Quality & Safety in Health Care 2006; 15: i50–i58
The Wayne Jowett Case
 Identify the SEIPS elements involved in this
case
http://www.smd.qmul.ac.uk/risk/videos.html#
SPACE
Interacting SEIPS Elements in the
Wayne Jowett Case
“Consultant –
Nurse –
Chart”
In
Consultation
Room
“Pharmacist
–Pharmacist
– Chart –
Drugs”
In
Pharmacy
Department
“Consultant –
Doctor –
Nurses –
Receptionist”
In
Reception
Area
TIME
“Nurse –
Drugs”
In
Pharmacy
Storage
“Nurse –
Doctor –
Registrar –
Patient –
Drugs –
Chart”
In
Treatment
Room
How do you apply SEIPS Systems
Thinking in practice?
 Recognise that interactions are central to the
care you provide within a particular complex
sociotechnical system
 Explore the interactions of different components
of the complex sociotechnical system in which
you find yourself
 Acknowledge not only the psychosocial
components of your system but also its physical
and organisational components and examine how
they impact your patient care
 Embrace complexity & uncertainty
The Old View of human error
on what goes wrong
The New View of human error
on what goes wrong
Human error is a cause of trouble
Human error is a symptom of
trouble deeper inside a system
To explain failure, you must seek
failures (errors, violations,
incompetence, mistakes)
To explain failure, do not try to
find where people went wrong
You must find people’s inaccurate
assessments, wrong decisions, bad
judgments
Instead, find how people’s
assessments and actions made
sense at the time, given the
circumstances that surrounded
them
The Old View of human error
on how to make it right
The New View of human error
on how to make it right
Complex systems are basically safe
Complex systems are not basically
safe
Unreliable, erratic humans
undermine defences, rules and
regulations
Complex systems are trade-offs
between multiple irreconcilable
goals (e.g. safety and efficiency)
To make systems safer, restrict the
human contribution by tighter
procedures, automation,
supervision
People have to create safety
through practice at all levels of an
organisation
Respiratory Lecture
Learning Objectives
 Integrate Human Factors Principles:
systems thinking & clinical human factors
skills
 Explore problem solving in action
 Develop an understanding of problem
solving theory
 Explore problem solving in a patient case
 Develop an appreciation of problem solving
theory applicability to clinical practice
Integrating Systems Thinking &
Clinical Human Factors Skills
Decision making
Managing stress
Communication
Coping with
fatigue
Team working
Situation
awareness
Leadership
Problem Solving in Action
Try to solve the following problem in groups of
no more than 3 people. You have 5 minutes!
 You are given 4 chains
of 3 links each as shown
below
 It costs £2 to open a link
and £3 to close a link
 Your goal is to connect
all chains, as shown
below, at a cost of no
more than £15
The Solution to the Cheap Necklace Problem
(Silveira, 1971; Fioratou & Cowley, 2009)
Fioratou, E., & Cowley, S. J. (2009). Insightful thinking: cognitive dynamics and material artifacts.
Pragmatics & Cognition, 17, 549-72
Systems Thinking in Problem Solving
Problem solving
behaviour emerged from
the interaction of your
team members, your task,
your tools, your
environment & our
organisation
How can we improve the interaction of
our system elements to solve the CNP?
Application to
clinical practice
The Elaine Bromiley Case
http://www.risky-business.com/talk-89-just-a-routineoperation.html
Working in groups of no more than 3 people, discuss
the following for this case:
 What System Elements (from SEIPS) can you
identify?
 What Clinical Human Factors Skills were involved?
 What problem solving aspects can you identify that
led to the unsuccessful management of this patient?
Linking the Bromiley case to the CNP
problem solving performance
In the CNP
In the Bromiley case
 Knowledge is necessary
but not sufficient for
problem solving success
 Persevering with the hillclimbing leads to fixation
and ultimately to failure
to solve the problem
 Expertise is necessary but
not sufficient for successful
case management
 Persevering with intubation
leads to fixation and
ultimately to patient death
Failure to escape fixation by capitalising
on cues in the environment
Suggested Actions from an
Independent Review (2005)
 Obtain and display a set of the latest DAS guidelines in each
anaesthetic room
 Develop a protocol to ensure that when any emergency
event occurs, be it in the anaesthetic room or the operating
theatre, there is someone designated to keep full
contemporaneous records of the event and to provide an
elapsed time prompt.
 Ensure an atmosphere of good communication in the
operating theatre such that any member of staff feels
comfortable to make suggestions on treatment.
 Organise a study day on airway management with particular
reference to equipment not regularly used and any
peculiarities
Strategies to Minimise Cognitive Errors
Develop insight/awareness
Consider alternatives
Heighten metacognition
Develop cognitive forcing strategies
Provide specific training
Decrease reliance on memory
Make task easier
Minimize time pressures
Improve feedback
Provide detailed descriptions and thorough characterizations of
known CDRs with multiple clinical examples illustrating their
adverse effects on decision making and diagnosis formulation
Establish forced consideration of alternative possibilities
Train for a reflective approach to problem-solving: stepping back
from the immediate problem to examine and reflect on the thinking
process
Develop generic and specific strategies to avoid predictable CDRs
in particular clinical situations
Identify specific flaws and biases in thinking and provide directed
training to overcome them
Improve the accuracy of judgments through cognitive aids:
mnemonics, clinical practice guidelines, algorithms, hand-held
computers
Provide more information about the specific problem to reduce task
difficulty and ambiguity. Make available rapid access to concise,
clear, well-organized information
Provide adequate time for quality decision making
Provide as rapid and reliable feedback as possible to decision
makers so that errors are immediately appreciated, understood,
and corrected, resulting in better calibration
Summary
 By exploring problem solving in action, we experienced how
heuristics may sometimes lead us to fixation and failure to
solve simple problems
 The applicability of problem solving concepts in clinical
practice can help us appreciate the limitations of our
cognitive powers and prepare us for future fixation recovery
 By exploring problem solving in the Elaine Bromiley case, we
experienced how clinical human factors skills may interact
with the particular system elements leading to fixation and
ultimately to patient harm
 We need to start learning and adopting strategies to minimise
our cognitive limitations
GI Workshops
(in preparation)
Year 2
 Dermatology Block
 Child & Family Block (in preparation)
Dermatology
Online Module
Learning objectives
 Understand the complexity of the dermatology
consultation from a Human Factors Science
approach
 Explore the affective component of clinical work
and understand the fundamental attribution error
 Reflect on your own emotions and develop
strategies against potential fundamental attribution
error
Child & Family Workshops
(in preparation)
Year 4
Transition Block 2
Workshops
Learning Objectives
 Introduction to Systems Thinking within Human
Factors Science
 Problem solving in action – introduction to
Systems Thinking in the lab & experimental
methodology
 Real patient cases – application of Systems
thinking in healthcare & naturalistic
methodology
Evaluating
 Feedback from students*
 Feedback from clinical teachers
 Learn from the feedback and improve
the programme accordingly…
Challenges
Integrating Human Factors principles
in clinical training and practice
 Human Factors information provided before it
becomes clinically relevant
 Dissonance between the Human Factors &
biomedical cultures
 Linking with other teaching (e.g., core clinical
problems, clinical skills centre, patient journey,
clerking)
 Inconsistent modelling of Human Factors principles
in the clinical setting
 My role and development as a non-clinical lecturer…
Solutions?
Human Factors integration
throughout the spiral curriculum
Co-ordination with clinical
colleagues but also acceptance of
individual differences & contextual
issues
Cultural change via leadership
Strategic Vision
To enhance the synergy between
Research and Teaching
and ensure sustainability
The Dundee Medical Graduate
 Core Human Factors Science knowledge &
skills (theory & methodology)
 Participation and/or leadership in Human
Factors projects impacting medical practice &
education
 Critical thinking in applying Human Factors in
their workplace
 Continuous professional development in
Human Factors at postgraduate level
Strategies for Sustainability
(Research & Teaching Initiatives)
 Local
~ collaborations with the School of Nursing, Institute of
Medical Science & Technology;
~ annual student journal publication/website/youtube
(Horizon-type) production of HF research and
experiences;
~ annual conference/awards/prizes for HF projects;
~ postgraduate supervision;
~ income generation (e.g., NES, HEA, CSO)
 National ~ e.g., collaborations with other medical
schools, SMERC, CHFG
 International ~ e.g., collaborations with DHI & DIMS
University of Dundee
School of Medicine
Thank you!
e.fioratou@dundee.ac.uk