Human Factors Engineering (HFE) refers to the study of human abilities and characteristics as they affect the design and smooth operation of equipment, systems, and jobs. The field concerns itself with considerations of the strengths and weaknesses of human physical and mental abilities and how these affect the systems design. Human factors analysis does not require designing or redesigning existing objects.1
Study, practice and motivation do not make a person mistake-proof. Each day experienced and well-intentioned clinicians go about their work in systems that are set up to fail them, further complicated by the set of human factors that individuals bring with them each day. “Most serious medical errors are committed by competent, caring people doing what other competent, caring people would do”2 but fortunately, most errors are minor or inconsequential but occasionally they cause serious harm. These mistakes are made, not because a person has made an incompetent error, but because their single act was the final link in a chain of errors and failures.
There are numerous human factors that influence the risk of patient harm but in general terms include:
1. Fatigue, related to work hours and workload
2. Team behaviours
3. Leadership and communication styles.
Sleep deprivation, night shifts and shift rotation all have a significant impact on performance by way of influencing levels of attention, judgment and reaction times. Heavy and/or stressful workloads lead to burnout and a consequential lack of motivation and diminishing attention provided to patients; predominantly not communicating effectively and failing to complete adequate documentation.
Team behaviours and leadership
Patient care, like other technically complex and high risk fields, is an interdependent process carried out by teams of individuals with advanced technical training who have varying roles and decision-making responsibilities3. Poorly functioning teams can undermine clinical performance and compromise the safety of care. In the UK, the reports of the Confidential Enquiries into Maternal Deaths have consistently cited lack of teamwork (and communication) in obstetric and midwifery teams and in multidisciplinary teams working among the causes of substandard clinical
care leading to ‘indirect’ maternal deaths.4
Communication skills, including active listening, are at the heart of health professionals interactions, whether with patients and family, or with other professionals. The failure to communicate or poor communicating/listening skills have been cited as one of the leading causes of inadvertent patient harm.5
Research has shown that poor communication between:
– patients and staff elicits most complaints about attitude and behaviour
– staff create ambiguity, ineffective transfer of information and therefore poor decision making.
Understanding the relationships of human factors invites us to consider our environment, and the context within where we work. In the case of hospitals and private practices, the workplace can be dangerous, diverse and busy with technical and non-technical skills. The team structure, its members, the dynamics and its ability to function and communicate will influence the potential for harm. Integration of risk management
strategies, learning and sharing safety issues and implementing solutions to prevent harm creates a setting that is capable of managing the human factors and as a result is healthy for staff and patients.
By Liz Fitzgerald
Clinical Risk Manager
“Medical Insurance Group Australia (MIGA) owns the copyright in this article and it is reproduced here with MIGA’s permission. This article shall not be reproduced elsewhere, in whole or in part, without the specific written permission of MIGA (phone 08 8238 4444). MIGA makes no warranty or representation nor does it assume any legal liability for the accuracy, completeness or usefulness of any information contained in this article. Anyone intending to act on any of the issues raised in this article should seek appropriate and up-to-date professional advice.”
Risk Management Tips
Human Factors – creating and managing a healthy team
– Make risk management part of your day-to-day business
– Acknowledge that most errors occur as a result of system failures
– Support an environment in which staff are encouraged to report errors and near
– Listen to staff concerns and facilitate change to avoid error and harm to patients
– Be alert for the human factors that may contribute to errors in your practice.
2 Donald Berwick MD MPP
4CEMACH (2004) Why Mothers Die 2000-2002. The Sixth Report of the Confidential Enquiries into Maternal Deaths in the
United Kingdom. RCOG press, London.
5 Leonard M, Graham S, Bonacum D (2004) The human factor: the critical importance of effective teamwork and
communication in providing safe care (Suppl 1 Simulation and team training): Qual and Saf in Health Care 13 i85-i90