In this essay, the writer (she) will discuss about human factors and how they will underpin patient safety, how effective communication is important and working together as a team. She will demonstrate what happens when things go wrong within the operating theatres, policies in place to protect the patients and guidelines to be followed by health professionals. The writer will investigate evidence-based practice and how this can improve patient’s safety. Human factors in health care is aiming to prevent errors that can be avoided within patient care and improving them by providing other ways of working through training, having the right equipment, information and good teamwork. Patient safety is about providing reliable care and achieving a measurable, specific realistic goal within a set time frame.
According to the international Ergonomics Association 2010, “[Human Factors] is the scientific discipline concerned with the understanding of interactions among humans and other elements of a system, and the profession that applies theory, principles, data, and other methods to design in order to optimise human well-being and overall system performance”.
Mistakes do happen but can be avoided if care is provided without pressure, stress, rushing or not having the skills and knowledge in doing the work properly. For example, the Elaine Bromiley case (Clinical human factors group 2011), all 3 anaesthetists couldn’t intubate or ventilate, and they were trying different things to try and get her airway. The nurses knew what had to be done to save her life and brought the right equipment to be used but with everyone doing their own thing with less communication, with no leadership, they put the patient at risk resulting in her death. Martine Bromiley set up a charity called the clinical human factors group after the death of his wife so that health professionals should learn from his wife’s death and avoid human errors. As humans we are not perfect, and we are subject to make mistakes, but we learn from them in being better by not repeating them and doing things differently. In Operating theatres there is no room for mistakes as some human errors can have severe consequences on a patient’s outcome. Not all can be avoided but it’s crucial to have a checklist to make it easier. The Operating theatre is recognised as a high-risk accident-prone environment where the consequences of failure can be catastrophic (Haynes AB, Weiser TG, Berry WR, 2009). Failures in non-technical skills mainly communication given by (Gawande A, Zinner MJ,Student DM, 2003). Teamwork has contributed to adverse events as demonstrated by (Catchpole K, Mishra A, Handa A, 2008).In healthcare, there has always been human errors being made whether it’s medical or mistakes due to negligence, bad judgment of poor communication within a team putting patients’ safety at risk, (Mid Staffs inquiry, 2010).
The Care Quality Commission (CQC) published a report in 2016 on the way the National Health Services (NHS) trusts in England review and investigate the deaths of patients which at the time was requested by the Secretary of State. It identified concerns relating to how bereaved families are treated, how deaths are reviewed, and how reviews and investigations are used to improve the quality of care (CQC,2016). In its report, CQC made several recommendations about how approaches to learning from deaths could be standardised across the NHS. These were accepted by the Secretary of State who asked the National Quality Board (NQB) to produce a new framework for the NHS. The NQB published learning from deaths national guidance as a significant step towards addressing the concerns identified by CQC in its report (NQB, 2017)The Health and safety authority have guidelines in place and monitors that these guidelines are followed to prevent errors happening at work putting service users at risk with their health. Employers arrange for their employees to undertake additional training to improve their skills and knowledge in using different equipments as some get replaced for better ones and training is needed. Policies are always changing and updated so healthcare professionals know what’s expected in providing effective care and support to patients. Patient safety extends to all areas of care within NHS anywhere and wherever people use the healthcare services and whatever diagnosis they have. The national patient safety team is legally responsible for delivering two statutory patient safety duties across the NHS. They are responsible for collecting information about what goes wrong in healthcare using the National Reporting and Learning System (NRLS) and using that information in providing advice and guidance.
According to a report; Our approach to patient safety the NHS is not learning as well as it could do when things go wrong, meaning that mistakes are repeated and opportunities to put in place effective systemic barriers to error are missed. (Our approach 2017-2018).Dr Mike Durkin, Director of Patient Safety at NHS England, said: “Patient safety has come a very long way in the past few years, and there has been a real revolution in how we monitor, manage and learn from incidents and build systems to minimise the risks of surgery. But every single never event is one too many. Many cause severe, life-changing harm and all of them damage confidence and trust in healthcare services (NHS England).Effective communication is very important in the Operating theatre as you need to be able to form a good working environment with your colleagues and know that you can turn to them for help and support should you ever need it. The Elaine Bromiley story provided that if everyone took a step back to think and assess the situation, then she could have had a better chance of surviving. There was no communication within the team. Everyone seemed to be trying different things. The nurses brought the right equipment for the surgeons to use but didn’t speak louder and clearer. It could have been because they felt they couldn’t speak up because of hierarchy in fear of being bullied. There wasn’t a team leader to guide and assess the situation and no one had a clear mind of what to do.
When working within a team, effective communication plays a big part in the operating department because you need to communicate verbally and clearly with your colleagues about what has been done or hasn’t. Working together in providing theskills each person is experienced in and avoiding mistakes happening for instance, giving medication twice not knowing the patient has already been given. Also, handovers or team briefs are vital as it gives you the chance to know what the patient has had and any medical problems new or old.Situation-Background-Assessment-Recommendation (SBAR) has been used for communication since the launch of 1000lives campaign in April 2008 and has helped communicate with patients effectively through their journey Written communication is important too for instance, care plans. They are designed to give information about a patient needs, medication and medical history making it handy for health professionals to meet the needs of the patients effectively. If not updated, they can give the wrong information leading to mistakes and mis-diagnosis occurring and preventing the patient getting the right care they need. In the NHS. (1000lives plus).Hogg and Vaughan (1995) discusses the way in which individuals occupying different roles in a group need to coordinate their actions through communication, though not all roles need to communicate with each other.
Having multi-disciplinary workers from different agencies coming to work in an operating department can affect the way a team communicate as some might not de-brief their team of were to get or find the right equipment, they need by assuming they know. Not communicating effectively with your team can cause mistakes and lead to not provide the best quality care to the patientAs a newly qualified healthcare professional you could be faced with a difficult situation where you know something isn’t right and speaking out could jeopardise your relationship with certain people or have conflict with your core workers. Fear of telling someone higher up that they are making a mistake as they might feel humiliated that someone below them with less experience has told them they have made a mistake.
The World Health Organization (WHO) Developed a WHO checklist in providing better communication in teamwork and mainly to reduce mistakes being made in not only surgery but in all the health care setting. This list not only used in the United Kingdom but all over the world. The surgical safety check list was introduced in 2009 with the aim of avoiding ‘never events. Evidence has proven the reduction of incidents happening within the clinical practice.
Never events are events that should never happen because there is enough guidance to prevent them. The task-force found that the 255 incidences of wrong-site surgery, wrong implant or prosthesis used, or objects being mistakenly left inside patients that were reported in 2012/13, were caused by a combination of factors. In the context of the 4.6 million hospital admissions that lead to surgical care each year in England, these incidents are rare. However, each never event is one too many.
In one of the trusts, a never event happened recently were a patient had a Seldinger chest drain inserted due to the presence of a pleural effusion. The chest drain wire was not removed following the insertion of the chest drain and was retained in the patient for 4 days. This was identified because there was a lack of readily available fit for purpose LocSSIP document prior to the chest drain being inserted. The patient received a review in a timely manner by the Acute Oncology Nurse and the incident was reported and recorded within the division. A duty of Candour was completed by the Consultant on identification of the incident.The Health and Care Professions Council (HCPC) regulations regarding patient safety was put in place so professionals behave in an acceptable manner when treating service users and providing safe care and good practice. By doing so, the HCPC is protecting the service user should any mistakes happen while in the care of any professional body. They Protect service users from being discriminated because of their view or ethics. It encourages people to be treated with respect and dignity regardless of where they come from or their appearance. Also, patient’s right to confidentiality meaning that their information can only be used for the purpose of their treatment and nothing else and seeking permission to use for other purposes. The Care Quality Commission (CQC) is always changing its assessment of quality in NHS organisations and focuses on developing an open culture encouraging learning from mistakes and being alert of risks happening. The Mid Staffordshire NHS Foundation inquiry is a good example of poor patient care. Sir Robert Francis QC published the report after several incidents were reported regarding patient safety and care in 2010. With evidence from over 900 patients current and former employees. In the report, those that tried to speak out were in fear of whistleblowing as they could face being bullied. It was the biggest scandal in the NHS since the Bristol children’s heart surgery scandal of the mid-1990s, in which babies lost their lives because doctors were not being properly checked. It led to the establishment of regulatory mechanisms to protect patients which the Mid-Staffordshire has shown to have failed.
The National Health Services (NHS) became the first and only healthcare system in the world to mandate the use of the World Health Organisation’s (Who) Surgical Safety Checklist in 2009 and this has shown to improve and build a safe culture. Evidence based practice plays an important role in delivering best patient care. The clinicians use theory-based research and knowledge in making decisions in delivering the best care to patients by taking into consideration individual needs, preferences and resources. There are clinical trials in place to test new drugs and equipment to improve patient’s treatment and recovery.Staying up to date with training and making sure medical equipment is serviced regularly also plays a big part in providing and improving patient safety. Simulations can improve improve the safety of health care by allowing health professionals to have valuable experience, in different clinical settings without putting patients at risk.
According to the British Journal of Anaesthesia (2012), Anaesthesia was one of the first healthcare specialities to embrace the team training and simulation model by developing ‘Anaesthesia Crisis Resource Management ‘(ACRM) training modules between late 1980s and the mid-1990s.The Health safety authority have guidelines in place and monitors that they are followed to prevent errors happening at work and putting service users at risk with their health or life.It is the governments priority in maintaining a safer environment and good service for patients and their families within the NHS.Working within a good team is important because you need to be able to help each other by bringing different skills and knowledge together to provide the best outcome. Also, unexpected events may occur meaning you will have to consult another member for support. According to Who, perioperative and anaesthetic-related mortality rates have progressively declined over the past 50 years, partially because of efforts to improve patient safety in the perioperative setting they remain 2 to 3 times higher in low-and middle- income countries than in high income countries. Hospital infection affect 14 out of every 100 patients admitted worldwide each year.
3.2 million patients affected with health care associated infections (HAIs) across Europe and 37 000 of them die. Infection prevention such as hand gels (hygiene) could reduce HAIs greatly.In conclusion, the awareness of human factors has been set mainly in clinical settings and guidelines put in place, policies mended and updated in providing patient safety and avoiding human errors. Avoidable errors are still being made within the NHS and the number of deaths due to this is still high and a lot still need to be done to improve the care and treatment for patients.