The Quality in Australian Healthcare Study found adverse events (unintended injury or complication caused by healthcare) occurred in 16.6% of hospital admissions, with 51% of these adverse events judged to be “highly preventable”. Death occurred in 4.9% of patients suffering an adverse event, and permanent disability in 13.7%. (Heard – Errors in Medicine: A Human Factors Perspective)
In this series of posts we explore why the safety frameworks that currently exist in healthcare may actually be detrimental to implementing effective solutions.
We’re killing our patients because we don’t understand human factors.
Well how could we? Today’s senior doctors and nurses were never taught about human factors during their training. We have thrived on a culture of education and academia. Those who are placed in charge of hospital departments have excelled. They are extremely bright, have often written numerous papers and are academically brilliant. Education and teaching has served them well – so of course this is where they look when presented with a problem or error – let’s teach it out. How couldn’t this work – it’s got them this far.
When frontline staff who understand human factors approach senior bodies with issues and their solutions they may be seen as agitators:
‘we don’t mind what you’re trying to do, it’s just the way you’re doing it’
‘no one else has complained about it’
Is that because it’s not a problem?
or is it because
– the people that hold the cards to fix the problems also hold the cards to our careers
– the less we criticise and just get on with it the better we believe we are at our jobs
– nothing effective will ever be done to fix the problem (learned helplessness)
– we don’t know enough about human factors
– we’ve been surrounded by latent errors and have just got on with it for so long
– we are too time poor to see a problem through to its resolution
– we hope/believe that someone else will fix the problem (diffusion of responsibility)
We need everyone to understand the human factors approach to healthcare. The safety frameworks need to change otherwise everywhere we turn we will hit a brick wall and the latent errors will continue to set the scene.
Patientsafe has provided some great resources to help staff head in the human factors direction. We all need to work together and make patient safety a priority if we are to overcome clinical error as the third biggest killer in our hospitals.