Following a medication error that led to the death of a patient, the nurse who administered the medication was sacked. Following an investigation by the Department of Health, no action was taken against the nurse or the hospital.
However, following an anonymous complaint, another investigation found deficiencies in hospital systems and also led to the nurse being charged with criminal homicide. No disciplinary action was taken against the hospital, but the nurse was found guilty of criminally negligent homicide. This article examines the series of events and comments on the impact of this case on the health profession and patient safety.
Despite our lives being shaped by the choices that we make, many people do not receive any training in making decisions. This article proposes that writing down key decisions in a diary, to be reviewed at a later date, provides an opportunity to learn and improve our decision-making process.
Five years ago, I launched this website with a series of articles about the Nimrod XV230 disaster.
Today, on the 15th anniversary of this tragedy, I’d like to reflect on the key recommendations. From the subtitle of the independent Review – “A failure of leadership, culture and priorities” – it’s obvious that there may be lessons for us all. The question is, have we learned these lessons?
A focus on individual behaviours is not the most effective approach to address workplace health and safety, unless all other necessary measures have been taken. Addressing behaviours should not be used to compensate for poorly-designed work or workplaces.
This article outlines the importance of the Hierarchy of Controls to determine the most effective measures to address workplace health and safety, and considers the position of individual behaviours within this hierarchy.
The COVID-19 pandemic has caused stress, anxiety, worry and depression for millions of people around the world as they confront illness, bereavement, unemployment and uncertainty.
However, the coronavirus may be causing another global crisis – inadequate sleep.
This article addresses the impact of lockdowns, home-working and quarantine on our sleep – and provides some practical solutions.
Making money on the stockmarket should be easy. Simply buy stocks, shares or managed funds when prices are low and sell them when prices are higher. This is basic mathematics! However, several studies have shown that the typical private investor buys when stocks are high and sells them when they are low.
The principles of human factors can help ordinary retail investors to make money (or not lose money) on the global stockmarkets. Many people lose money when trading or investing on the stockmarket simply because we are human. We act on our emotions or instincts, and we are subject to cognitive biases (errors of thinking). These human factors can lead us to make poor decisions and lose money.
Frequent and rapid changes in workplaces around the world to control the coronavirus pandemic have the potential to harm the mental wellbeing of millions of people. Prior to the pandemic, mental health was a significant workplace issue and there will be significant increases in mental health issues due to the coronavirus pandemic.
However, there are steps that employers can take to promote mental wellbeing in the workplace and this article outlines what organisations can do to create a mentally healthy workplace, particularly during the coronavirus pandemic.
Governments and the media have provided information on how to stay physically safe during the pandemic, but guidance on looking after our mental wellbeing has been less visible. Unfortunately, the actions taken to stay physically safe, such as isolation and physical distancing, may be having a harmful effect on our mental health. Research on previous disasters shows that they create a long shadow of mental health issues, trailing the disaster by months or years.
Although vaccines are available for the coronavirus, there is no vaccine to support mental wellbeing.
In addition to the effects on individuals, mental health issues can have a significant impact on human reliability in the workplace. This article provides eight tips to maintain or improve your mental wellbeing during the COVID-19 pandemic.
During the COVID-19 pandemic, up to 64% of the global aircraft fleet was in storage (around 17000 aircraft) and tens of thousands of pilots were also grounded for many months. The human factors implications are significant.
This article explores, through the lens of selected human factors topics, some of the challenges airlines face as they resume commercial flights. To illustrate these challenges, I explore recent incidents. The approach taken in this article may be helpful for organisations restarting activities, or making changes to activities, following the COVID-19 pandemic.
High Reliability Organisations (HROs) operate in complex, high-risk environments where accidents might be expected to occur frequently, but they actually have fewer than might be expected. However, recent thinking suggests that what defines a HRO is not safety or reliability performance, but how it thinks and acts. The key is that HROs anticipate the unexpected AND contain the unexpected when it occurs.
The current COVID-19 pandemic has highlighted the importance of the best practices of the HRO approach. This article outlines the five key characteristics of HROs in order to help organisations respond to the COVID-19 pandemic and other future unexpected events.
Trevor Kletz was a safety hero. Over a career spanning nearly 70 years, his thoughts on human factors, human error and accident investigation helped to move the industry from a focus on individual behaviour to organisational and system failures. His proposal that we should shift from blame to learning is the basis of current safety thinking.
The ‘ironies of automation’ refers to a set of unintended consequences as a result of automation, that could detrimentally affect human performance on critical tasks. Automation might increase human performance issues, rather than eliminate them.
Measuring the workload that people experience is important, because subjective workload has an impact on human performance. A high workload eats into our limited mental resources and can lead to errors, near-misses and incidents. Workload is often measured by the resources available (such as nurse-to-patient staffing ratios), but workload is experienced differently by different people. For example, two nurses assigned to the same number of patients in the same Intensive Care Unit may experience workload differently due to the stability and complexity of their patients. Therefore, a subjective measure of workload can provide helpful insights beyond traditional measures such as staffing ratios. One of the most common measures of subjective workload developed by the NASA Human Performance Group is now available as an App and can be applied in any industry.
Each year, thousands of people are killed in road accidents due to drivers being distracted by their mobile phone. Despite awareness campaigns, people continue to use their smartphones whilst driving. This article outlines some of the reasons why smartphones can be addictive and provides some practical tips to help manage the relationship we have with our devices.
This article was prompted by the 2019 television drama series ‘Chernobyl’, and focuses on human error, safety culture and designing for safety. It provides some discussion points to engage with your key stakeholders and to facilitate safety moments.
The UK NHS (National Health Service), like healthcare in other countries, is a complex system. It is one of the largest employers in the world – some NHS Trusts employ around 20,000 staff and have a turnover of more than £1 billion. The NHS is not a single organisation – there are many parts that make up the NHS. However, these components do not operate as separate entities, they are interconnected and work together as a system. This creates challenges for those that lead these organisations. A recent report on leadership by The King’s Fund: “Leadership in today’s NHS: Delivering the impossible” questions whether senior leadership roles in the NHS are still “do-able”.
Could you be killed by a car tonight? You’re perhaps thinking that I’m referring to a road traffic accident – as an occupant in a vehicle, or maybe as a pedestrian or cyclist. But there’s another way that you could be killed by a car tonight – YOUR car in fact. And this isn’t a reference to the Stephen King novel “Christine”, about a car apparently possessed by supernatural forces. This article examines how a technological change has led to tragedy. Please share this “safety moment” with family, friends and colleagues.
How do we “think”? And what’s the role of Working Memory in thinking?
Little has been written about Working Memory in relation to human performance in the workplace – and so in this article I introduce the concept of working memory, discuss why it’s important and provide some advice on managing it’s limitations.
12 questions to ask in an investigation – getting behind the label of ‘human error’
This article highlights some common misconceptions about fatigue and sleep. Fatigue can lead to poor performance on tasks which require attention, decision-making or high levels of skill.
Around the world, children die from hyperthermia every year after parents unintentionally left them in a hot vehicle, often for a full day. This article examines these tragedies from a human factors perspective, and provides some tips to prevent it happening to your family.
It also asks whether we can learn from these events to improve human performance in the workplace.
A significant proportion of road accidents involve driver distraction. Many drivers admit to making calls, reading or writing messages, and checking social media whilst driving.
Using mobile phones can cause drivers to take their eyes off the road, their hands off the steering wheel, and their minds off the road and the surrounding situation. This article outlines how using a mobile can affect driving behaviours, and increase crash risk (even if using a hands-free device).
What is human factors? Do you have difficulty explaining the topic to others? And what value does human factors add? This article examines the factors that might influence a control room operator’s behaviour (Homer Simpson) and how we might improve his human reliability.
These ‘Performance Influencing Factors’ are key to optimising human performance. The post provides a definition of human factors: “making it easy for Homer to do the right thing”.
Human error is a central concept in ergonomics and human factors. But what is ‘human error’? Is it helping us to improve safety? The language we use may be preventing us from learning or improving.
In this article, I discuss a better way of thinking about human error.
I find these ten facts about human failure a great way to engage delegates on human factors training courses.
This post also discusses Performance Influencing Factors, the things that make human failures more or less likely.
I was heavily influenced by a HSE publication ‘Organising for Safety’, led by Dr Donald Broadbent. This post provides a key conclusion from this report and considers its relevance over 20 years later.
Violations of procedures are a significant cause of many workplace accidents. This post introduces this type of human failures and includes a Briefing Note with strategies to prevent violations.
Nimrod XV230 was due to a catalogue of organisational failures and the lessons are relevant to any high-hazard or complex organisation.
In this article I provide ten questions to help stimulate discussion and reflection on leadership, culture and priorities.
Discusses the relationship between complexity and system failures. The author of The Nimrod Review, The Hon. Mr Justice Haddon-Cave, states that simplicity is your friend and complexity is your enemy.
Organisational change is inevitable, but does it have to lead to disaster? Whatever it is that defines ‘safety’ for your organisation, whether that is keeping chemicals in the pipes, keeping trains on the tracks, airplanes in the sky, or not harming patients; it is essential that any significant organisational changes are assessed for their impact on safety. This will include assessing changes to: roles and responsibilities, organisational structures, reporting relationships, staffing levels, staff location, outsourcing, use of contractors, delayering, downsizing and centralisation of functions. This article discusses two aspects of any change that need to be assessed and managed.