Health Care Education: The Human Factor
Thursday, 02 May 2013
From 1900 to 2100
Medico-Chirurgical Hall
Dr Rona Patey - Director, Medical Education Unit, University of Aberdeen
Notes
Minute of meeting of the Society held on 2nd May 2013 in the Society Hall, Foresterhill. Dr Ken McHardy presided.
Having welcomed those attending, the President introduced the speaker, Dr Rona Patey, consultant anaesthetist and Head of Medical and Dental Education, University of Aberdeen. Her subject was Healthcare Education. The Human Factor.
Dr Patey started by saying that things do not always go right and showed photographs of various well known disasters, including a ‘plane crash at Kegworth, the Piper Alpha oil rig disaster, the Herald of Free Enterprise (a ferry which set to sea with its bow doors open and capsized), Chernovl (a nuclear plant explosion), a train crash and sportsmen who made wrong decisions.
She then asked ‘what about healthcare?’ and mentioned some well known mistakes such as wrong side surgery and wrong blood or fluid or drug administration. No such mistakes are intentional but adverse event analysis shows that 80% of medical mistakes have human factors which are preventable, including inattention, distraction, haste, fatigue and poor communications.
Scientists have looked at broader organizational issues such as the organisation’s culture, leadership, hazard reduction schemes and communications. Inpidual workers need to have situational awareness and have ability to manage stress and fatigue.
Dr Patey mentioned Reason’s ‘Swiss cheese’ model of accident causation (Reason BMJ 2000 768-70) Some ‘holes’ may be made by an active failure such as a person making a mistake but others will be due to latent conditions such as culture or poor leadership. Telling people not to make mistakes does not work but training can reduce the incidence. Changing latent conditions is more difficult and more costly and they are more difficult to identify.
She talked about ‘change blindness’ and illustrated this by showing an image for 15 seconds. Despite showing it twice, nobody noticed that one part of the image slowly changed. Her point was that we are ‘hard wired’ not to notice gradual change so, for example, it is easy not to notice when a patient is slowly deteriorating. She said that everybody is fallible and takes shortcuts but behavior can slowly migrate to become more dangerous although such changes can be hard to detect.
Dr Patey then made reference to other industries especially the aviation industry where human factors in safety are part of core training; adverse event reporting is compulsory and there are systems for briefing and debriefing. In aviation, early accidents were often due to technical failures but technology and training have improved. Mistakes were more likely to be made by senior pilots for complex reasons including culture but the industry now regards all accidents as being preventable. She played a recording, accompanied by an animated film, of the two minute journey of Flight 1549 which suffered a bird strike just after take off, lost power from both engines and made an emergency landing in the Hudson River with all on board surviving. Learning points were that the captain and co-pilot had prior agreement as to actions to be taken in such an eventuality, that the captain stayed in control and made his own decisions with little reference to air traffic control, but that others were also taking pre-rehearsed actions both on board and at air traffic control who cleared three runways for the aircraft.
Returning to healthcare, Dr Patey described haw patient safety is becoming a core component of undergraduate and post graduate curriculae including teaching about human factors. Simulation gives options for training but role play is also used. She mentioned the ‘clinical human factors group’ www.chfg.org.
After several questions, the President proposed the vote of thanks and presented Dr Patey with a copy of The Heritage of the Med Chi.