One in ten people is affected by medical error. Not all errors lead to harm, and not all harm is due to error. An adverse event is an unintended injury caused by medical management rather than the disease process.
There are three common factors in the majority of adverse events: medical complexity, system factors and human factors. Common human factors that can increase risk include: mental workload, distractions, the physical environment, physical demands, device/ product design, teamwork, process design.
This is why our aim within the Human Factors programme is to develop the non-technical skills to support safer ways of working – these include teamwork, communication, leadership and an awareness of human factors when designing systems and processes. 80% of incidents are as a result of human factors.
What are we doing?
We have awarded £65,000 in funding to four community organisations to support the roll-out of Human Factors training for support staff.
Communication and team working are recognised to have significant impact on the quality of safe services for patients. Following the Cavendish Review, the Care Certificate specified standards for support workers (Bands 1 – 4) working in all NHS and social care settings.
Although an appreciation of the principles of Human Factors has been implemented in acute care services in recent years, it has been found that training packages and resources are less applicable to the community health and social care context.
Health Education South West has therefore funded the West of England AHSN to develop an intervention using the SBAR tool (situation, background, assessment, recommendation) to support Human Factors training in patient safety focussing on support works in community settings.
The curriculum for this training was developed by Sirona Care & Health and North Bristol NHS Trust. It is based on how teams communicate and uses communication tools such as SBAR to develop a baseline awareness, which is built upon and embedded during the training using different scenarios. These scenarios were co-designed by the programme lead and service user representative to reflect realistic scenarios that staff might encounter.
To date, 435 staff from community organisations have already received Human Factors training and over the next 18 months we are supporting five member organisations (Bath & North East Somerset CCG, Bristol Community Health, Gloucestershire Care Services and North Somerset Community Partnership) to train a further 2,500 staff working in the community setting.
In conjunction with North Bristol NHS Trust and Sirona Care & Health, we are also training up to 45 facilitators across the region in order to create a faculty with specialist knowledge and experience in Human Factors training for community services.
An integral factor in developing our programme has been co-production with patients and service users. You can hear from one of our service users, Stephen, about the impact this has had on him or read this case study produced by the Healthcare Quality Improvement Partnership.
Building capacity to support human factors in patient safety toolkit
We have developed a toolkit to support organisations to implement human factors within their teams.
You may find it handy to print out this step by step checklist for implementing the project to guide you through your implementation.
What are human factors?
Just a Routine Operation teaching video is a guide to the concept of human factors in healthcare.
What is SBAR?
SBAR is a structured method for communicating critical information that requires immediate attention and action, contributing to effective escalation and increased patient safety. The SBAR tool originated in the US Navy Submarine Service and was adapted for use in healthcare by Dr M Leonard and colleagues from Kaiser Permanente, Colorado, USA.
Watch these videos to find out more…
What is quality improvement?
In order to implement human factors in a sustainable way in your organisation, and to be able to measure the impact of this intervention, we recommend a structured Quality Improvement framework for implementation.
Our approach uses the methodology developed by the Institute of Healthcare Improvement called the IHI Model of Improvement. You can find out more about the Model for Improvement through our Improvement Journey available here.
Watch this video for an introduction to Plan Do Study Act (PDSA) cycles.