In 2005 my late wife died as a direct result of medical errors during an attempted routine operation. A subsequent independent review identified that a well equipped operating theatre and a team of clinicians all technically skilled had failed to respond appropriately to an unanticipated emergency. They had failed to follow protocols, use equipment properly, maintain situational awareness, prioritise and make decisions appropriately. Leadership was confused, communication problems arose despite attempts to speak up by the team and any benefit of the team skills and awareness present was lost. In short, human factors not technical inability led to my late wife’s death.
Healthcare culture often inadvertently conceals systemic problems and in the past has laid the “blame” on certain individuals. But to me this is fundamentally flawed thinking. It wasn’t the clinicians that failed; it was the system and training that failed them. The protocol was not clear, rehearsed and briefed, the use of equipment not well rehearsed and understood, techniques for maintaining situational awareness were not explicitly understood or encouraged, leadership skills required and the dangers of fixation were not experienced or understood by the team; and at no stage was more open communication explicitly encouraged in the organisation or by the clinical leaders at the moment of the emergency. To me as an airline pilot this was obvious because of the culture I work in and the training I have received; but to those on the 29th March 2005 this was learning on the job.
I decided to do some research. I had no plan, I had to bring up two young children and keep a roof over our head. But I felt that others should be able to learn from what had happened. I assumed Elaine’s death was a one off, but clearly it wasn’t. I assumed maybe healthcare was in good shape, it was just this team in this location, but it wasn’t. All the learning about ergonomics/human factors in aviation and other industries seemed to have reached the hospital gate and gone no further. As I started to talk to people, I found examples of excellence in healthcare, clinicians who really understood human factors, but they were in very small isolated pockets. Someone somewhere needed to help coordinate their work and publicise it. I spoke to people I thought might be able to do that, but no one seemed to be willing or able, or maybe they just didn’t understand. By 2007 it was clear; if no one else would do it then I would have to do it myself.
Since 2007 the Clinical Human Factors Group, originally inspired by the Royal Aeronautical Society Human Factors Group has developed aiming to promote understanding of human factors in healthcare from Board to Ward and beyond. I assumed we would face similar problems to those in aviation, but I realised very quickly that healthcare is a very complex set of disparate tribes, centralised regulation is very weak, centralised policy actively challenged or ignored, and political power and tribal loyalty confused. The state of healthcare isn’t the result of carefully planned and focussed efforts driven by a need to maintain or improve safety; it’s the result of hundreds, even thousands of years of inertia, denial and vested interest which have created an organisation more akin to the teaching professions of old or the church. Of course where is the patient, and 21st Century clinician in all this?
Now healthcare seems to understand that it should have more in common with other safety critical industries. Human Factors is a developing science in healthcare, and is intrinsic to a myriad of different processes. Change will inevitably move at a different pace within different processes and healthcare organisations. We are all part of this learning process and I’m really encouraged, and humbled that so many significant people are prepared to part of us to make a difference.
The CHFG has one significant advantage over other healthcare organisations –we are not held back by the inflexibility of bureaucracy or organisation. Please don’t think of traditional healthcare organisational structures, think more campaign and activist with the power of respected world class experts in our group who are trusted for their independent, considered and thoughtful support and guidance. We have the ability to push where others can’t and it is vital that as we grow and develop we retain these vital capabilities.
This discussion document aims to lay out in simple terms what human factors and the CHFG are about and our vision for a safe and more efficient healthcare system for patients and clinicians. It also aims to set out our strategy.
Founder and current Chair of the CHFG, June 2011