Factoring the human into Patient Safety. Rhona Flin. IV Internacional Conference on Patient Safety (Madrid, Ministry of Health and Consumer Affairs, 2008)

1. Factoring the Human into Patient Safety
Rhona Flin,
Industrial Psychology Research Centre
Patient Safety Research Group
IV Conferencia International de Seguridad del Paciente
Madrid, 25 November 2008

2. Welcome to the Industrial Psychology Research Centre. The centre specialises in the application
of psychology to high reliability workplaces.
The group has worked with the oil industry since 1986, and regularly engage in consultancy
projects. We are currently working with the offshore oil industry, civil aviation, nuclear power
generation, surgery, emergency services, conventional power generation and transportation.
Interests of the centre include:
•Accident analysis
•Incident command
•Occupational stress
•Emergency decision making
•Crew Resource Management
•Measuring and managing safety culture/climate
•Human factors aspects of safety management and emergency response
Clients include: Agip, AKER, AMEC, Amerada Hess, AMOCO, British Energy, BHP, BP, Brown & Root,
Chevron, Civil Aviation Authority, Coflexip Stena, Conoco, Defence Evaluation and Research Agency (DERA),
EC (DGTREN), First Group, Halliburton, Health & Safety Executive, KBR, Kerr McGee, Morgan Stanley,
National Power, NHS, Novartis, Powergen, Royal College of Surgeons, Salamis SGB, Schlumberger, SCPMDE,
Shell, Talisman, Texaco, Total, Transocean,, UBS Warburg & UK Nuclear Imc.

3. www.spsrn.ac.uk

4. Human Factors
“Human factors refer to environmental,
organisational and job factors, and human
and individual characteristics which
influence behaviour at work in a way which
can affect health and safety.”
Health and Safety Executive (1999)
Reducing Error and Influencing Behaviour
www.hse.gov.uk/humanfactors

5. Human variability: Two aspects
(Reason, 2000)
Human as
Human as
hazard
hero
• Slips • Adjustments
• Lapses • Compensations
• Mistakes
• Recoveries
• Violations • Improvisations

6. Safe and Efficient Performance
Individual actions
Latent Conditions
Professional
Behaviour
Organisational
/Professional Job
Technical
Culture Performance
Non-Tech.
Skills
A B c

7. ABC
• A – antecedents eg organisational culture
– Norms of behaviour
• B – behaviour
• C – consequences – reinforcement
– Rewards or punishments for particular
behaviours by supervisors, peers etc, builds
culture

8. Organisational Safety
Technical
Factors
Accident
Causation
Culture/
Human Worker
= Manager +
Factors
Behaviour
Behaviour

9. The complexity of hospital cultures
a) ‘A confusion of languages’
b)Who are the leaders?
nominal leaders
e.g. Management
but
powerful informal leaders
e.g. Consultants

10. Safety culture and behaviour
• Worksites with more positive safety culture
show lower accident rates
• Workers who perceive their supervisors/
managers to be more committed to safety
engage in more safety-related behaviours and
fewer risk taking behaviours
• Motivational mechanism linking culture to
behaviour – expectations/ rewards linked to
behaviour of managers/ supervisors (Zohar, 2002)
( Landy Conte 2006)

11. Safety culture questionnaires

12. Safety Culture Dimensions
• Prioritisation of Safety
(production vs. safety)
• Management commitment to safety
Safety systems, training, communication,
resources, incident reporting systems,
feedback, accident analysis, teamwork,
organisational support etc etc

13. Key worker safety behaviours
Speaking up about safety
Reporting incidents
Participation in safety activities
Rule compliance/ Risk taking

14. Leadership Style for Safety?
Transformational leadership (Bass) is the strongest predictor
of safety in industry (Flin Yule, 2004, Quality Safety in Healthcare)

15. How do Senior Managers foster
an unsafe culture?
• Sending the wrong signals by their:
– language
– behaviour
– priorities
– time allocation
• Upward appraisal of senior managers’ safety
leadership (e.g. healthcare CEOs)

16. Changing the culture
• Clarify priorities
• Provide safety resources (inc. time)
• Reward appropriate behaviours
• National initiatives (Government driven)
• Licensing and revalidation
• Patient safety education for healthcare students
• Training safer behaviours (non-technical skills)

17. Tenerife (1977)
Two Boeing 747s crashed into each other on the runway.
583 people killed.
Causes: conflict resolution, assertiveness, communication,
situation awareness, stress – non-technical skills

18. Human Performance Limitations Training
• Understanding of physiological and psychological
factors influencing task performance
–eg stress, fatigue, work conditions
• Pilots trained at ab-initio stage
• Pilots have to pass an exam in this
• No evidence of this type of training
in Medical Schools

19. Pilots’ Non-Technical Skills
• Term non-technical skills first used in
European civil aviation.
• ‘Cognitive and social skills of flight
crew members in the cockpit, not
directly related to aircraft control,
system management, and standard
operating procedures’.
• NOTECHS – is a taxonomy and
behaviour rating system for pilots’
non-technical skills developed in
Europe
Flin et al (2003) Development of the NOTECHS system
for assessing pilots’ CRM skills. Human Factors and
Aerospace Safety, 3, 95-117.

20. Generic Non-Technical Skills
• Leadership
• Team Work / workload management
• Communication
• Situation Awareness
• Decision Making
• Personal Limitations – managing
stress and fatigue

21. Clinical Human Factors Group
www.chfg.org

22. Non-Technical skills, error and
adverse events
Identify Non-
Technical Skills
Error
Poor Non-
Unsafe Increased chance
Technical Skills
behaviours
Train and
assess using
Adverse event
ANTS/
NOTSS etc
Safer
Good Non- behaviours Decreased chance
Observation, rating
Technical Skills Avoid/
and feedback
Capture Error
using behavioural
rating system

23. Anaesthetists’, Surgeons’ and
Scrub Nurses’ Non-Technical Skills
University of Aberdeen, NHS Education Scotland,
Royal College of Surgeons of Edinburgh

24. Anaesthetists’ Non-Technical
Skills
ANTS
Task Team Situation Decision
Management Working Awareness Making
Planning
preparing Category
Prioritising Element
Providing Behaviour
maintaining standards
Identifying utilising Checks equipment, prepares drugs for the case
resources

25. Non-technical skills taxonomies
Surgeons: www.abdn.ac.uk/iprc/notss/
Anaesthetists: www.abdn.ac.uk/iprc/ants/
Nurses: email: l.mitchell@abdn.ac.uk
Project sponsors:
Royal College of Surgeons of Edinburgh (RCSEd)
NHS Education for Scotland (NES)

26. Patient Safety Education
• Medical Schools (eg Aberdeen)
– Year 5 module on patient safety
– Year 1 survey of knowledge/attitudes to patient safety
• WHO patient safety curriculum: medical students (for 2008)
• Canada: Patient Safety Competencies (for 2008)
• Australia: Patient Safety Education Framework (2005)
– www.patientsafety.org.au
• MSc Patient Safety (Imperial; Aberdeen)
– Clinicians and healthcare managers

27. Further information
• r.flin@abdn.ac.uk
• www.abdn.ac.uk/iprc
lists of projects and papers and reports
Scottish Patient Safety Research Network
www.spsrn.ac.uk