Safety
Situation Awareness in Midwifery Practice
| Document
|
Author Rachael L. Martin & Paul Bowie |
| Abstract Situation Awareness (SA) is commonly defined as “the perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future” (Endsley, 1995:36). From this cognitive perspective, SA is synonymous with perception or attention, and involves a continual monitoring of the status quo for changes that might require action by frontline operators (Flin et al 2008). Within the midwifery literature, “loss of situation awareness” has been cited as a contributory factor to adverse events and unwanted clinical outcomes (HSIB 2020; Knight et al 2014; RCOG 2017). This operationalisation of SA is problematic for multiple reasons which are explored in this discussion paper. The paper begins by exploring the transferability of human factors lessons between safety critical industries such as aviation and healthcare. Different theoretical perspectives on SA are evaluated, highlighting that the theoretical concept has been misapplied in midwifery, with distinct differences from Endsley’s original model in how it is defined and measured. The paper provides an overview of the difficulties in measuring SA, which limit the prospective utility of the construct. Furthermore, retrospective identification of loss of SA is value laden and subject to hindsight bias. This stands in opposition to the Human Factors systems approach where “human error” should be viewed as a symptom of systemic problems within an organisation, rather than a causal factor (Amer-Wahlin and Dekker, 2008; Shorrock and Williams 2016). This paper proposes that a more holistic perspective is required which considers the individual clinician within the context of the wider sociotechnical system, rather than focus solely on the performance of individuals. It is vital to identify the system factors which may lead to loss of situation awareness, in order to redesign the work environment to minimise patient harm and maximise safety (Singh et al 2006). Opportunity also exists for further research to investigate whether an alternative model of SA may be more appropriate for use in the healthcare context generally, and maternity care specifically, better reflecting the complex system in which clinicians work. |
Factors Contributing to Task Success: Safety-II in the Context of Community-Based Patient Discharge
| Document
|
Author Eva-Maria BURFORD, Bill BROWN, Mike FRAY and Patrick WATERSON |
| Abstract This explorative study investigated Safety-I and Safety-II elements in six focus groups with experienced staff involved in the patient discharge process from a community perspective. The elements explored included defining a good discharge, potential errors, influencing factors, weak signals, learning opportunities, and elements that assisted in achieving a successful task outcome. Key findings included identifying person-, task-, and organization-related examples that promote a good discharge. The weak signals and elements aiding success were categorised using the SEIPS 2.0 model. |
Assessing pilots’ situation awareness on Future Systems Simulator
| Document
|
Author Laurie Marsman, Dominique Bovell, Stuart Christie, Brian Green & Beatriz Martinez Gutierrez |
| Abstract The present paper reports the results of a trial investigating pilots’ situation awareness in the Future Systems Simulator (FSS). Both PF and PM positions and accompanying tasks in the simulator are considered. Moreover, a follow-up session with current airline pilots in the study provides perspectives on the practical application of the FSS. |
Ergonomic mismatch between university student anthropometry and classroom furniture in Tanzania
| Document
|
Author Jecha Suleiman Jecha, Samia Rafique & Hui Lyu |
| Abstract The standard and guidelines of school furniture dimensions have been developed in many countries, but it’s never been explored for university students in Tanzania. This study evaluated the potential mismatch between classroom furniture dimensions and anthropometric characteristics of 289 Zanzibar university students (167 females, 122 males) aged 17- 27 years. The results indicated high rates of mismatches between the body dimensions of the students and the existing classroom furniture, with seat height (100%), desktop height (93.08%), and seat width (81.40%) being the furniture dimensions with higher level of mismatch and backrest height with a lower level of mismatch (66.26%). The findings suggest that the least developed countries should improve school furniture design based on anthropometric results to avoid or minimize student discomfort and MSD problems. |
An exploratory focus group study of factors influencing helicopter pilots’ Non-Technical Skills
| Document
|
Author O. Hamlet, A. Irwin, R. Flin, & G. Thomson |
| Abstract Non-technical skills are the interpersonal and cognitive skills that promote effective performance alongside a pra2ctitioner’s technical abilities in their working environment. Whilst helicopter pilots are trained and assessed in non-technical skills, there is a lack of encompassing research assessing the factors which influence these skills as a whole. The current study aimed to report and compare factors which influenced the utilisation of non-technical skills across two pilot groups; search and rescue and offshore transport. Fifteen semi-structured focus group sessions were undertaken (n=8 offshore transport, n=7 search and rescue) where pilots were asked a series of open-ended questions centred around factors that influenced their non-technical skill utilisation. Focus group analysis was conducted by way of inductive thematic analysis to identify and compare factors. Workload, stress, individual influences, crew interaction/composition, environmental influences, changes and the status of other non-technical skills were identified as overarching factors which influenced the utilisation of pilots’ non-technical skills. Each factor consisted of a range of specific elements. While there was no variation between pilots on a factor level (e.g. workload), there was significant variation on the elemental level (e.g. too high a workload for offshore transport vs. not having all relevant mission information for search and rescue). The results indicate that while there are similarities in the overarching factors that affect non-technical skill utilisation, variations exist on the elemental level. Non-technical skills training, therefore, should be adapted for specific mission types and focused around role specific elements. |
Needs for resilient fire safety management on land and sea
| Document
|
Author Helene Degerman and Staffan Bram |
| Abstract Fires are associated with potentially large consequences for life, environment and property and are therefore an important aspect in workplace design. This article summarises two case studies, examining the preconditions for a well-functioning fire safety system on land and at sea respectively, applying a systems perspective on work and safety. Today’s fire safety management is mainly focused on technical installations, constructional and building measures, control plans and evacuation routines. Fire safety installations could meet all regulative requirements and still create problems for production, sometimes to the point where fire protective routines or installations are bypassed. A common answer to such issues is to strengthen administrative barriers such as rules, safety information and training. However, in tightly optimised organisations like heavy industries or shipping, more checks and routines will only run the risk of aggravating the problem at hand. The problem could instead be viewed as an effect of poor design. Flaws in fire safety design can be traced to the processes of ship and industrial workplace design, building and revision. In the observed fire safety design processes, there are no established ways to ensure that end-user needs are taken into account, and the construction project's main incentive is to keep the construction cost down. Instead, costs are pushed to the operational phase in the form of reduced production and lower safety levels. Safety management in general, and fire safety management in particular, needs to be further developed from a systems perspective. |
Addressing staffing crises in transfusion without compromising safety
| Document
|
Author Simon P Carter-Graham, Jennifer Davies, Emma Milser, Debbi Poles & Shruthi Narayan |
| Abstract A presentation of data submitted to Serious Hazards of Transfusion (SHOT), the UK's Haemovigilance scheme. Data subject is training and competency of healthcare professionals in temporary roles, such as locum or agency. |
Ranking priorities for safety improvement: a study of methods
| Document
|
Author Anthea Ashford, Liz Hellier and Andrew Weyman |
| Abstract Effective safety management relies on the identification of vulnerabilities. Tapping employee insights is a valuable source of intelligence. Of the array of qualitative and quantitative elicitation techniques, staff surveys are the most commonly encountered: psychometric measures of situational influences on workplace climate provide a valuable means of benchmarking and monitoring. However, they afford little insight about the relative importance of the constituent themes – they are essentially silent on the issue of prioritising topics for intervention. In recognition of this, an arising question relates to determining the strengths and limitations of alternative elicitation techniques. The study reported here compared the performance of three widely used methods of priority elicitation techniques: direct ranking, Q-sort and the method of paired comparisons, for a set of nine features of workplace safety climate. Results showed high agreement with respect to the rank order produced by the three methods. A point of contrast was that the interval scale output from the method of paired comparisons provided an indication of the relative difference (proportional importance) between the variables. However, this method was lengthier to complete. The relative merits of the three methods and the implications for eliciting priorities in safety management are discussed. Areas of future research were identified to develop these measures further for use in the safety management arena. |
Improving Control Of Work: Addressing Human And Organisational Factors And The Experience And Lessons From Early Implementation In The North Sea
| Document
|
Author Neil CLARK and John WILKINSON |
| Abstract Just because you have a permit does not make you safe. This paper describes an aviation-inspired human and organisational factors (HOF) approach to improving one major oil and gas company’s Control of Work (CoW) system. The challenge was finding the right balance between control/rigour and usability/compliance. Methods included: structured baseline setting (HOF audit, incident review and survey); active user involvement; collaborative design with training and technology providers, HOF specialists; good practice review (aviation sector); system – including procedural – usability improvements. Early results are promising and the approach has already been adopted by other major operators. |
Assessment of Leadership and Management for Safety – where do we start?
| Document
|
Author Jonathan BERMAN, Shona WATSON and Michael ARGENT |
| Abstract |
Can We Learn about Human and Organisational Factors from Past Transfusion Errors?
| Document
|
Author Alison WATT, Gyuchan Thomas JUN, Patrick WATERSON |
| Abstract Seven human factors models were evaluated using a small number of historical transfusion error reports to explore learning from human and organisational factors to decide the best model for a larger retrospective study. Insufficient information given in many reports led to subjectivity in categorisation, but the conclusion was that the systems engineering initiative for patient safety 2.0 may be the best single system to use. Analysing the human factors effectively in transfusion incidents could provide some insights into process improvement. |
Supporting Safer Work Practice Through the Use of Wearable Technology
| Document
|
Author Judy Bowen, Annika Hinze, Jemma König and Dylan Exton |
| Abstract Forestry has the highest accident rate of any industry in New Zealand. One of the known contributors to accidents is worker fatigue, which can be attributed to the long working days and physically (and/or mentally) demanding nature of the work. Wearable technology is increasingly being proposed within work environments as a way of supporting workers in different tasks and monitoring workers in hazardous environments. However, in most cases ‘off the shelf’ wearables are not fit for purpose in rugged outdoor environments. Over the past five years, we have conducted numerous studies and undertaken research into the use of wearable technology in New Zealand forestry. The work aims to address existing problems by developing ethical and evidence-based wearable technology which is suitable for forestry workers. We describe the development of a smart vest for forestry workers along with key insights gleaned from the development, design and testing processes. |
Recreational Boating Safety: A Systems Analysis of the Causal Factors Contributing to Accidents
| Document
|
Author Helen Wordsworth, Patrick Waterson & Will Tutton |
| Abstract Recreational boating has become an extremely popular past-time in the UK, particularly since COVID-19, with boat equipment sales up by 25%, compared with pre-pandemic levels. Wilson (2022) predicts a further 11% growth in sales in 2021-2022 and the market is currently exceeding pre-pandemic trading levels. We used a set of 12 Accimaps to analyse of contributory factors leading to recreational boating accidents documented by the MAIB. The data from the Accimaps was then used to scope a set of questions which formed the basis of two surveys. One survey was for members of the public involved in recreational boating and the other for professional individuals involved in the recreational boating community. Key findings were that lack of training, knowledge and preparation were seen as key reasons leading to unsafe boating situations, in addition to recklessness. Most participants wore lifejackets whilst boating and approximately 50% thought alcohol consumption was acceptable at some point during a boating trip. Boat/sailing clubs were seen to reinforce good safety culture but outside of clubs was less positive. Some recommendations were developed following the study. It would be beneficial to introduce a mandatory qualification prior to the purchase of any motorised vessel, such as that employed in Australia or similar to the International Certificate for Operators of Pleasure Craft (ICC).It may be worthwhile developing more interactive, nationally consistent signage at popular launch locations. A final recommendation would be to place some responsibility on manufacturers. |
All too unfamiliar? A study to investigate the human factors that cause incidents in hire cars
| Document
|
Author Daniel Healy |
| Abstract Many studies have attempted to understand why driving hire cars can be dangerous. Many attribute the cause of incidents to a lack of familiarity with the driving environment or hire vehicle. This study hypothesises that it is a lack of familiarity with both vehicle and driving environment that are the cause. Using Klein’s Critical Decision Method (CDM) to draw out the mental models of five expert drivers who have been involved in incidents either at home or abroad, this paper delves deeper into the underlying causes and examines the effects of applying existing mental models to unfamiliar scenarios. A summary analysis into the causes behind each incident is provided along with a case study for two of the most insightful interviews. The insights from the interviews are used to create recommendations for safer driving practices within the hire-car industry. |
Collisions at Sea: A Systems Analysis of Causal Factors and Countermeasures
| Document
|
Author Simon MURRAY, Patrick WATERSON, Thomas JUN |
| Abstract Despite established and proven prescriptive safety legislation, accidents regularly occur across all sectors of shipping. Of particular concern is the number of collisions that continue to occur, even when experienced and trained officers are on board and modern navigation aids are in use. Using a systems approach, this paper will highlight common contributory factors, which can lead to collisions and then propose a set of countermeasures which can be used to reduce these types of shipping accidents. |
Leading behaviours in Highways England
| Document
|
Author Claire Philp & Nigel Heaton |
| Abstract As part of a 5-year health and safety plan, Highways England has embarked upon an ambitious leadership and behavioural safety Programme. We provided leaders with a wide range of tools to try when they went back to work. We found that the most popular tool in these leaders’ action plans is COM-B, a model used to explain behaviours. Leaders also adopted other tools to support the development of a just culture, improvements in wellbeing, and mapping risk at a local level. The training programme has improved the self-evaluations of key management areas and appears to have driven safer behaviours. Overall, we have found that if leaders are equipped with tools and understanding of the problems they face, are followed up, and are offered on-going support, they are willing to make real changes to the way they work and approach health and safety. |
Making the Right Choices: Behavioural Safety for Designers on a Construction Project
| Document
|
Author Shelley Stiles |
| Abstract Behavioural safety programmes are widely used across the Construction Industry, largely targeted at influencing behaviours of frontline workers and/or leadership behaviours. However, there is limited application of behavioural safety at the pre-construction (design) phase of a construction project, given the importance of the design community in eliminating and mitigating health and safety risks. This paper details a case study for the application of behavioural safety intervention targeted at the design community for a large infrastructure project. |
Mountain guides’ everyday work: Articulating safety and service relationship
| Document
|
Author Antoine Girard, Sandrine Caroly and Pierre Falzon |
| Abstract With a worrying accidentology (ten fatal accidents per year for approximately 1700 professionals in France), a culture that promotes a high level of performance and a profession based on the craft-type approach, the practice of mountaineering with a guide can be considered as an unsafe system (Amalberti et al., 2005; Morel et al., 2009). This practice has two particular characteristics. Firstly, it is currently undergoing a deep transformation not only in terms of its environmental context (with global warming), but also because of the media, legal and regulatory pressure that weakens the sustainability of the profession, due to low safety standards. Secondly, it belongs to the service situations. The client is present and involved in the production phases (Falzon and Cerf, 2005): they may be a novice or more experienced and may themself be a victim of accidents. For instance, fifteen clients died in 2018 in France. If, for the guide, clients are a variable to be monitored in a dynamic situation (Hoc, 2001), they are also participants, with their own goals, in the interactive process of the service relationship (Falzon and Cerf, 2005). This service situation, where a professional applies specific skills to provide the service requested by the client, should be distinguished from situations of cooperation between two operators (Falzon and Cerf, 2005; Flageul-Caroly, 2001). According to these elements, this study examines the way the guides build safety with their clients, in a hazardous, dynamic environment and in this particular socio-professional context. |
The Impact of Wearing Facemasks on Pilot Non-Technical Skills During the COVID-19 Pandemic
| Document
|
Author Craig M Kerr & Jim Nixon |
| Abstract Masks on the flight deck are a part of an overarching biosecurity strategy intended to keep aircrew safe during the COVID-19 pandemic. The objective of this research was to explore pilot perception of the impact of mask wearing on non-technical skills. Four key non-technical skill areas were identified: communication, situational awareness, task management and decision making. Flight-crew perception on how mask wearing affects these skills was captured using a questionnaire. In addition, overall pilot attitude to mask wearing was captured concurrently. Sixty-two pilots with a variety of experience and backgrounds participated in the research. Analysis revealed communication to be a skill heavily impacted by facemasks. Results also align with the IATA risk assessment suggesting facemasks increase the time taken to don oxygen masks in the event of rapid depressurisation. The burden associated with flying whilst wearing masks also became evident. Flight-crew report increased feelings of fatigue when wearing masks, impacts upon crew resource management and performance. Overall, findings suggest that masks impact non-technical skills and subsequently crew resource management. These findings indicate that mask wearing might adversely affect flight safety. These findings should be considered when decisions are made to implement mask wearing in the cockpit. |
Lessons learned in collaborative working to address rail freight safety risks
| Document
|
Author David Golightly, Ann Mills, Dougie Hill & Roberto Palacin |
| Abstract Rail freight safety is key to delivering effective, low carbon transport. The Great Britain rail sector has identified a number of risks to address and a programme of work in order to improve safety. However, the multi-stakeholder nature of the rail freight sector in Great Britain can present challenges when addressing those risks. This paper presents a study to identify lessons learned in the execution of collaborative work to address one of those risks – establishing Common Safe Systems of Work. Seven interviews with key stakeholders in the Common Safe Systems of Work project were analysed for learning points to take forward in addressing other rail freight safety risks. 16 learning points were identified with an emphasis on effective project scoping, project governance, communications and clarifying responsibilities. |
Reverse Swiss Cheese – Driving Safety Culture from the Blunt End
| Document
|
Author Barry Kirwan, Ben Wood & Beatrice Bettignies-Thiebaux |
| Abstract For two decades, Swiss Cheese theory has been an influential metaphor in safety science and accident prevention. It has made barrier theory and the impact of safety culture on operational safety more understandable to the upper echelons of high-risk organisations in many industrial sectors. Yet sometimes the Swiss Cheese model is used to focus on the operational ‘sharp end’ and unsafe acts, like a magnifying glass that acknowledges organizational influence, but still targets the human operator. It is time to ‘turn this lens around’, and allow organisations to focus on the upstream factors and decision-making that can engender these unsafe acts in the first place. This paper reports on an approach to do this, under development in the Maritime sector, called Reverse Swiss Cheese. |
Summoning the demon? Identifying risks in a future artificial general intelligence system
| Document
|
Author Paul M Salmon, Brandon King, Gemma J. M Read, Jason Thompson, Tony Carden, Chris Baber, Neville A Stanton & Scott McLean |
| Abstract There are concerns that Artificial General Intelligence (AGI) could pose an existential threat to humanity; however, as AGI does not yet exist it is difficult to prospectively identify risks and develop controls. In this article we describe the use of a many model systems Human Factors and Ergonomics (HFE) approach in which three methods were applied to identify risks in a future ‘envisioned world’ AGI-based uncrewed combat aerial vehicle (UCAV) system. The findings demonstrate that there are many potential risks, but that the most critical arise not due to poor performance, but when the AGI attempts to achieve goals at the expense of other system values, or when the AGI becomes ‘super-intelligent’, and humans can no longer manage it. |
Psychophysiological coherence training reduces pilots’ perceived stress in flight operations
| Document
|
Author Laurie Marsman, Jingyi Zhang & Wen-Chin Li |
| Abstract The present paper reports the results of a four-week study assessing the relationship between psychophysiological coherence training, which aims to improve the synchronisation between one’s physiological rhythms leading to a positive emotional state, and perceived stress levels in commercial air transport pilots. Next to three self-report stress questionnaire measurements, qualitative data were gathered as well to gain more insights into the training effects. Results show significant reductions in the flight crew’s perceived stress levels during the four-week psychophysiological coherence practice period. Finally, the results are discussed. |
Virtual reality training: Making construction work safer
| Document
|
Author Dr Shelley Stiles |
| Abstract The Construction Industry damages over 60,000 underground services each year, a significant cost and risk to human life. Training is an established aspect of safety management, and research recognises the importance of interaction and engagement to enhance the training experience and increase knowledge retention. Despite this, often training sessions are delivered via traditional presentation – an approach lacking in the focus on engagement for a positive impact on learning outcomes. The use of virtual reality technologies within a safety context is becoming more commonplace, but there is limited evidence that this type of training intervention can improve safety performance with a reduction of accidents and incidents. The work presented evaluates the effectiveness of 360° film and virtual reality technology as a safety training intervention delivered to workers on construction projects. This study has evaluated the impact of this safety intervention on the number of service strikes for one principal contractor organisation over a two-year period – a case study. Services strikes are when workers accidentally dig through underground utilities. The delivery of 85 training sessions was found to have a positive impact on safety outcomes, with a 32% reduction of services strikes following 12 months of training. It is concluded that the use of 360° film virtual reality technology as part of a safety training intervention can have a significant impact improving safety outcomes. |
Using human factors to enhance drug prescribing safety
| Document
|
Author Joanne Carling, Gillian Janes & Dave Murray |
| Abstract Preventing harm by ensuring medications are prescribed accurately for patients on admission to hospital is a patent safety priority and one that should be achievable. A human factors systems analysis of the process of medicines reconciliation revealed some possible solutions to reducing drug prescribing errors for patients admitted to a hospital in England. Medicines reconciliation is a process that ensures the medication prescribed for adults in hospital corresponds to pre-admission. It aims to avoid errors such as unintended omissions, over prescribing, dosing errors or adverse drug reactions. Inadequate medicines reconciliation on admission is commonly identified as a major cause of patient morbidity. Poor access to patients’ regular medications lists is recognised as a particularly important factor. The System Engineering Initiative for Patient Safety model was used to analyse the barriers to effective medicines reconciliation in adults on admission. This model clearly recognises the interrelated nature of the five major aspects of work systems: people, tasks, tools and technologies, physical environment and organisational conditions. Adopting this approach enabled a broader, more effective analysis of the problem which identified some fundamental issues with the current process and barriers to effective medicines reconciliation which were otherwise unknown. The findings revealed how work system elements interact and the importance of acknowledging this when trying to resolve a problem like improving medicines reconciliation, rather than focusing on the behaviour of individuals. Dissemination of the findings and implementation of the recommendations arising from these also helped the organisation to appreciate the value of human factors in understanding human performance and enhancing safety. |
Safety Risk Attitudes in Commercial Aviation
| Document
|
Author Johnny Short, Eric Tchouamou Njoya & Nick Hubbard |
| Abstract The commercial aviation industry is a human-built and human-led system. Hazards are identified, assessed and managed by people. Perceptual dissonance induces inherent subjectivity, and this has the potential to reduce the efficacy of safety risk management. Whilst perception is a key driver of risk attitudes, evidence to show the impact of their proactive management is limited. This case study aims to demonstrate the rationale for further research. |
Adaptations to everyday work amongst nuclear operators: A safety-II approach
| Document
|
Author Robin Hamer, Gyuchan Thomas Jun and Patrick Waterson |
| Abstract The safety-II movement has recently been gaining momentum. Most of the work has been conceptual in nature; however, some efforts have been made to apply Safety-II thinking in a practical manner. Current safety-II based methods have been criticised as being difficult to administer and complicated to understand. Although some research has been carried out to address safety-II, there is still some ambiguity about how the construct can be applied in practice. One way forward is to understand adaptations that occur in normal everyday work. This can be achieved by contrasting work-as-imagined and work-as-done in the context of the work environment. One understanding of this is to capture and analyse such adaptations and demonstrate value by sharing good practice. The current case study was undertaken at a major British nuclear installation. The research aims were to understand and learn from normal every day work done by nuclear operators, more specifically the adaptations they make to successfully navigate their work. A mixed methods study design (document analysis, contextual inquiry and interviews) was selected to obtain a complete understanding of work-as-imagined and work-as-done from two selected tasks, common in a nuclear power plant. Semi-structured interviews were administered to nuclear personnel who performed the tasks. These were subsequently transcribed and coded to extract the adaptations. 47 adaptations were elicited and interpreted using an analysis framework, adapted for use in the nuclear industry. The framework enabled adaptations to be classified and provided new insights into how and why the adaptations occurred. The findings were reviewed by human factors practitioners at a major UK nuclear operator. The consensus was positive, and a potential benefit of application was recognised – in particular the new information on adaptations to review tasks and rewrite standard operating procedures. |
Safety Climate – Revealing the ‘X Factor’
| Document
|
Author Stuart SHIRREFF and Andrew BAIRD |
| Abstract |
Setting the standard: a systems approach to the design and evaluation of safety standards
| Document
|
Author Tony Carden, Paul M. Salmon and Natassia Goode |
| Abstract In 2003, adventure activity providers in Victoria, Australia, began to develop a set of common operating standards. The resulting Victorian Adventure Activity Standards became a model for similar standards in other Australian states. However, the development process lacked systematic rigour. This article argues that sociotechnical systems theory methods are suited to safety standard design and evaluation. A Work Domain Analysis revealed system weaknesses along with potential avenues for modifying and optimising the standards. Potential improvements and broader implications are discussed. |
The Pressures Diagram: Illustrating Pressures and Trade-offs in Healthcare
| Document
|
Author Natalie Sanford, Mary Lavelle, Ola Markiewicz, Gabriel Reedy, Anne Marie Rafferty & Janet E. Anderson |
| Abstract Healthcare is challenged by pressures on every level of the system. This short paper introduces the Pressures Diagram as a tool to communicate pressures and the prioritisation of pressures, affording greater insight into the complexity of healthcare work. |
Investigations by acute-hospital staff: AcciMaps or HFACS?
| Document
|
Author Nick Woodier, Karen Whiting & Owen Bennett |
| Abstract For many years the classical approach to healthcare incident investigation has been Root Cause Analysis (RCA). However, healthcare has faced increasing criticism for failing to learn from when things go wrong and for investigations that are ineffective. There is a need to better support healthcare staff, who may have limited training and experience in investigation, to undertake more effective patient safety investigations. The authors aimed to identify an appropriate and usable patient safety investigation method for use by healthcare staff. The result of a literature review and engagement with experts led the authors to focus on the Human Factors Analysis and Classification System (HFACS) and AcciMap. Prior to evaluating the methods, HFACS was adapted to the acute hospital context by developing a coding set based on the original codes. Through workshops the authors identified a clear preference for HFACS. Its prescriptive nature appealed to investigators in that it considered all aspects of their systems and highlighted the potential contributory factors; it was felt to have face and content validity. HFACS presents a much-needed prescriptive model for investigators from varying backgrounds and experience. It is usable, appropriate, valid and reliable. The HFACS codes may require further development for different contexts, having been developed here for acute hospitals. |
Unpacking Safety-II in action: Weak Signals of Potential Error in Patient Handling Tasks
| Document
|
Author Eva-Maria BURFORD, Mike FRAY and Patrick WATERSON |
| Abstract As a result of a new definition of safety, whereby the focus on the ability to succeed under varying conditions is emphasised, new opportunities for assessing and improving safety are being developed. This study investigated both Safety-I and Safety-II elements using a focus group method with two expert groups in patient handling. The Safety-I and Safety-II elements investigated included potential errors, weak signals and learning opportunities arising from these situations. The weak signals that were identified were classified as originating from either an external or internal source. Potential learning opportunities to improve signal recognition were identified. |
Taking control without guidance: What do drivers of semi-autonomous vehicles think about?
| Document
|
Author Kirsten Revell, David Keszthelyi, James Brown & Neville Stanton |
| Abstract Cars that can drive themselves are nearly with us and semi-autonomous vehicles are already on the road. The largest gap in our understanding of vehicle automation is how drivers will react to this new technology and how best to design the driver-automation interaction. This study focuses on what drivers pay attention to at different stages of a planned handover from vehicle to driver. Thematic analysis was conducted on think aloud ‘verbal protocol data’ from drivers interacting with a SAE (Society of Automotive Engineers) L3 semi-autonomous vehicle using a driver simulator. Focusing particularly on verbalisations indicating Situation Awareness (SA) which is linked to safe transfer of control, and post handover drive, the type and proportion of verbalisations before, during and post handover was captured. During handover, it appeared that drivers minds were directed towards the interaction rather than the road ahead, suggesting safety may be compromised. Examining pre-handover data it was seen that SA verbalisations were very prominent in the 20 seconds prior to engagement when it was expected that drivers would be focused on their secondary task. A level of vigilance pre-handover may therefore negate the frequency of SA verbalisations during handover. The nature of SA verbalisations also change at different stages of handover. Pre and during handover there is a far greater emphasis on ‘checking road conditions’ and commenting on ‘positive road conditions’ compared to post handover where the focus is on other road vehicles and speed. Implications for interaction design in semi-autonomous vehicles is discussed. |
The systemic causes of medication problems for hospitalised children
| Document
|
Author Adam Sutherland, Suzanne Grant, Stephen Tomlin, Denham L Phipps, & Darren M Ashcroft |
| Abstract Medication processes are chaotic and complex, and assumed to be undertaken by specific professionals in isolation from other healthcare tasks. However tasks are delivered simultaneously and adaptively because of the complexity of healthcare provision. This study aimed to explore the systemic contributory factors to medication related problems in children’s wards using multiple qualitative methods (230 hours participant observation and 19 semi-structured interviews). There is insufficient resource available to undertake all the processes to ensure safety; decisions about medicines were made with reference to immediate problems only; parents were relied on to administer medicines to children, and; there was widespread non-compliance with interventions to improve safety because they conflicted with day-to-day work. |
Identifying resilience: A system safety review of trauma and orthopaedic theatres
| Document
|
Author Victoria E. Wills, Andrew Seaton |
| Abstract A system safety review to assess the resilience in Trauma and Orthopaedic (T&O) theatres was conducted in response to a number of Never Events. The imminent publication of the Patient Safety Incident Response Framework (PSIRF) paved the way for an alternative to traditional serious incident investigation, proposing a systems-based approach and enabling subsequent improvements to be based on ‘work as done’, rather than ‘work as imagined’. Analysis identified opportunities for interventions that built system resilience, which were developed and tested by front line staff as part of a Quality Improvement (QI) collaborative. The approach demonstrated a practical application of the integration of systems theory, patient safety, resilience engineering and quality improvement approaches. |
Complex Systems’ Safety: an example from Naval navigation
| Document
|
Author Mike Tainsh |
| Abstract This work addresses the development and application of an ergonomics contribution to the process of safety assessment for complex systems. The approach is general, but in a Naval context. |
A qualitative exploration of forestry chainsaw operator non-technical skills
| Document
|
Author Amy Irwin1, Ilinca-Ruxandra Tone, Paulina Sobocinska & Jason Liggins |
| Abstract Non-technical skills are the cognitive, social and personal management skills considered necessary, alongside technical knowledge, for safe and effective work practice. Despite forestry operations, particularly those involving a chainsaw, being extremely high-risk, these skills have not yet been examined in the forestry context. This study used qualitative interviews to explore the non-technical skills relevant to forestry chainsaw operation, with preliminary findings highlighting skills such as situation awareness, task management and decision-making as vital for forestry worker safety. |
Exploring the complexities of cane rail operations in Tropical Far North Queensland
| Document
|
Author Anjum Naweed, Matthew JW Thomas, Janine Chapman and Jason Hajinakitas |
| Abstract Rail-based transportation is the backbone of agriculture in the raw sugar supply chain. A high-pressured industry, rail-based service delivery corresponds with mill productivity, but the nature of this environment renders it prone to derailment and conflicting moves. Despite the pace at which cane operations are evolving to accommodate rising industry growth, there is little to no published literature of the human factors in cane rail operations, or a common understanding of how the peculiarities in this system impact risk and the way that drivers work. A total of five focus groups were conducted with locomotive crew (n = 19) from an organisation in tropical Far North Queensland. Data was collected using a scenario-based technique which involved the creation of challenging everyday scenarios. Data analysis examined features of challenging scenarios, and specific categories of risk. Preliminary results illustrate cane-rail operations as a highly complex, dynamic and opaque system with a myriad of inherent risks that make the work undertaken by locomotive crew particularly challenging. Future research directions are given. |
Predicting driver safety: A methodology for small samples
| Document
|
Author Louise Bowen and Andrew P Smith |
| Abstract Research suggests that driver safety is reduced by driver fatigue, risk-taking and inappropriate driver behaviour. These effects can be combined to produce a single strong predictor. The present study examined whether this approach was sensitive enough to detect effects in a small sample (N = 103) who had a low annual mileage (about 5000 miles). The study identified correlated attributes of the main predictors and examined whether these added to the model. The results confirmed the predictive power of driver fatigue, risk-taking and inappropriate driver behaviour. They also showed that the effects of other correlated variables did not add to the predictive power of the model. Other important features of the approach included the development and use of short measuring instruments, adjustment for the social desirability bias and use of an outcome measure combining road traffic collisions and near misses. |
Ergonomics of paragliding reserve deployment
| Document
|
Author Matt Wilkes, Geoff Long, Heather Massey, Clare Eglin, Mike Tipton and Rebecca Charles |
| Abstract Paragliding is an emerging discipline of aviation, which is considered relatively high risk. Reserve parachutes are rarely used, but typical deployments are at low altitude, with pilots under the extreme stress of a life-threatening situation. To date, paraglider equipment design has focused primarily on weight and aerodynamics, so reserve parachute deployment systems have evolved haphazardly. Our study aimed to characterise deployment behaviours in amateur pilots. Fifty-five paraglider pilots were filmed deploying their reserve parachutes from a zipline. Test conditions were designed for ecologically valid body, hand and gaze positions; cognitive loading and switching; and physical disorientation akin to a real deployment. The footage was reviewed by two groups of subject matter experts. It was noted that pilots searched for the reserve handle using the hip as an anatomical landmark and tried to extract the deployment bag upwards, irrespective of optimum direction. Recommendations, which are being incorporated into the latest draft of the European Norm for harness design included: positioning reserve handles at the pilot’s hip; better system integration between different manufacturers; and containers being designed so deployment bags are extractable at any angle of pull. Deployment in a single, sweeping action should be encouraged in preference to the multiple actions sometimes taught. |
Human Factors Integration (HFI) in UK Healthcare: a route map for 1 year, 5 years, 10 years and 20 years
| Document
|
Author Sue HIGNETT, Will TUTTON, Kerry TATLOCK |
| Abstract This paper reflects on Human Factors Integration (HFI) to consider how Human Factors/Ergonomics has influenced Defence activities, and could influence safety and performance in Healthcare activities. A workshop with 16 Chartered Institute of Ergonomics & Human Factors members was held in July 2016 to discuss and propose a Route Map for HFI in the UK National Health Service. The results set out achievable targets for 1, 5, 10 and 20 years culminating in mandatory HFI to achieve a resilient system for safety culture and work load. |
