In April 2005 Elaine Bromiley died as a result of problems during routine surgery. A report produced by the then President of the Association of Anaesthetists of Great Britain and Ireland identified serious errors during her time in surgery. In summary, Elaine died as a direct result of clinical errors. Among the three consultants (from two different specialities) there was a collective loss of situational awareness, and apparently failures in decision-making, prioritisation and ultimately leadership during a recognised emergency for which guidelines existed. Among the four nurses there was an apparent inability to communicate directly or intervene (although they tried) despite a general awareness of what was actually occurring and what should have been occurring.
Elaine’s husband, Martin had over 10 years’ experience as an airline pilot, including time specialising as a ‘human factors trainer’. Culturally, he had seen much happen in his business to improve safety, where error is now accepted as something to be expected and managed, and so people work hard to catch it.
After Elaine’s report, Martin started to look at human factors in healthcare. He met many champions of ‘human factors’ within clinical practice and it was obvious that if all this knowledge could be harnessed, it would make a real difference. Unfortunately, many people continued to work independently. Often this was because of organisational boundaries, or people were simply unaware of the good work that was already going on in the UK. Martin also realised that there was a tremendous lack of appreciation of human factors at the front line, not through ignorance but because of a lack of information.
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Martin was inspired by the progress made in aviation and so looked back at the history of human factors development. The picture had been the same in UK aviation. Back in 1990 a group of frustrated industry experts formed a ‘human factors group’ with the aim of ‘improving standards of safety in aviation by promoting a better understanding of human factors hazards and techniques for dealing with them. Members place their commitment to the aims of the group before any commercial or party interests.’
This group became part of the Royal Aeronautical Society in 1994, where it still works today. The Standing Group is made up of volunteer experts, who provide the lead for smaller industry sub-groups who work in specialist areas to develop industry practice. The Civil Aviation Authority, the industry regulator, includes one of these sub-groups as an ‘advisor’ on human factors policy and practice, and indeed regard the group as the industry lead body. Almost everything practiced day to day in aviation human factors has come from the work of the group and sub-groups. They have, in effect defined and led the cultural change.
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