Quality Education for a Healthier Scotland
Multidisciplinary
The nature and reality of working safely
Mark Johnston
Training and Research Officer
(Patient Safety)
NHS Education for Scotland
0131 656 3258
@markjohnston71
Quality Education for a Healthier Scotland
Multidisciplinary
Ergonomics and Human Factors
•Known as Human Factors in the United States,everywhere else Ergonomics; they mean the samething!
•Ergonomics from the Greek – Ergo “Work” andNomics “Laws of”
Therefore the discipline is concerned with the laws that governhuman work.
•Uses methods to evaluate human work in order tooptimise well-being and performance of individualsand organisations
Quality Education for a Healthier Scotland
Multidisciplinary
You’re amazing!
Quality Education for a Healthier Scotland
Multidisciplinary
Quality Education for a Healthier Scotland
Multidisciplinary
Factors impacting on an individual thatcontribute to error
•Stress
•Fatigue
•Illness
•Hunger/Thirst
•Hazardous attitudes
•Language and cultural factors
These are NOT Human Factors, these are theconsequences of not adopting Human Factors.
Quality Education for a Healthier Scotland
Multidisciplinary
Human FactorsA common language
“…the scientific discipline concerned with the understanding of interactionsamong humans and other elements of a system, and the profession thatapplies theory, principles, data and methods to design in order to optimisehuman well-being and overall system performance.”
International Ergonomics Association
Cognitive
Organisation
Physical
Human
Quality Education for a Healthier Scotland
Multidisciplinary
Domains of Ergonomics and Human Factors
Physical ergonomics - human anatomy,anthropometry, physiological and biomechanicalcharacteristics as they relate to physical activity.
Cognitive ergonomics - mental processes, such asperception, memory, reasoning, and motor response,as they affect interactions among humans and otherelements of a system.
Organisational ergonomics - sociotechnical systems,organizational structures, policies, and processes.
Quality Education for a Healthier Scotland
Multidisciplinary
Summary
Key points
•Ergonomics and Human Factors mean the samething
•The Twin aims are enhanced well-being andperformance of individuals and organisations
•These aims are interdependent
•It is a scientific discipline; 4yr degree course +practice + specialisation
Quality Education for a Healthier Scotland
Multidisciplinary
Bad people?
Errors occur due tosystem design and howthose designs influencebehaviour
Why do errors happen?
Quality Education for a Healthier Scotland
Multidisciplinary
Even experts err
Quality Education for a Healthier Scotland
Multidisciplinary
The dilemma of “human error”
If 1 event out of 100,000 goes wrong, humans areassumed to be responsible in 80%-90% of cases
It follows that
If 99,999 out of 100,000 events go right then humansare responsible in 80%-90% of cases
Which outcome results in investigation?
Quality Education for a Healthier Scotland
Multidisciplinary
Inaction, Breach, Violation, Loss of Situation Awareness– all are just substitute terms for ‘Human Error’
•Human Error is not the cause
•Human Error is a symptom
Quality Education for a Healthier Scotland
Multidisciplinary
Captain Hindsight
Quality Education for a Healthier Scotland
Multidisciplinary
Why don’t we (usually) bump intoeach other?
![C:\Users\MarkJ\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.IE5\W1A29MUD\crowd[1].jpg](data/images/img8.jpg)
Quality Education for a Healthier Scotland
Multidisciplinary
Our response...
Safety 1 – focuses on what went wrong and tries tocontrol by introducing further restriction(pre work view - little or nothing goeswrong, contradicted by hindsight)
Safety 2 – facilitating the performanceadjustments that are necessary foreveryday work to succeed.
People not systems are intrinsically safe!
Quality Education for a Healthier Scotland
Multidisciplinary
So….handwashing. How is that goingfor you?
What for you is the front linereality of trying to implementthose guidelines and bestpractice? Safety 1
Would a safety 2 approachhelp?
Quality Education for a Healthier Scotland
Multidisciplinary
Tips for Safety 2
•Look at what goes right, as well as what goes wrong
•Things do not go well because people simply follow theprocedures. Things go well because people make sensibleadjustments according to the demands of the situation. Find outwhat these adjustments are and try to learn from them
•Work is Vs work as imagined (do people follow the rule all thetime?)
•A small improvement of everyday performance may count morethan a large improvement of exceptional performance
•Allow time to reflect, to learn, and to communicate (Be mutuallyaccountable)
Adapted from Van Stralen
Quality Education for a Healthier Scotland
Multidisciplinary
It goes right more than it goes wrong
•Celebrate that
•Be curious as to why
•Change Culture? Choose your attitude.
Quality Education for a Healthier Scotland
Multidisciplinary
The nature and reality of working safely
Mark Johnston
Training and Research Officer
(Patient Safety)
NHS Education for Scotland
0131 656 3258
@markjohnston71