4th Clinical Human Factors Group Seminar, Cambridge 23.10.12

I’m just heading back from the 4th Clinical Human Factors Group meeting in Cambridge and again it didn’t disappoint. I’ve been to three now and each time I am impressed with the passion that people show at this meeting, and particularly the engagement of the clinical community.

Suzette Woodward, @SuzetteWoodward, gave a very inspiring talk to kick things off. She had been one of the London Gamesmakers and outlined what an important role they played: lots of different people had come together to inspire, to be alert, open, consistent, part of the team and to have fun. Being from London and attending the games I had witnessed what a difference they made – and it was remarkable. Suzette brought forward her learnings from the experience and made a case for how we each need to be inspiring ambassadors for Human Factors in healthcare. I think I will promote Human Factors work I do to the clinicians I encounter in my research as a result of this, but one question still remains: should we have Adidas uniforms for this?

This was followed by Peter Buckle and Janet Anderson who explained the limitations of standardisation in dynamic complex systems; followed by Lauren Morgan and Matt Inada-Kim who explained the importance and success stories of standardisation in complex systems. This tension was intentional as there doesn’t seem to be a straight forward answer in determining the degree of autonomy and flexibility or strict adherence to rules and procedures in complex systems. The correct answer will be revealed in hindsight… and if everything goes right no one will care anyway as this is what the system is meant to do.

My own lunchtime market place presentation of www.errordiary.org was well received, but it would have been nice speaking to more people. I outlined the purpose of Errordiary as threefold: 1) to raise awareness about the pervasiveness of human error in a non-threatening way, which seems to be particularly effective as an ice-breaker in healthcare where human error is so serious and can have far reaching repercussions e.g. people can associate with putting their red pants in the white wash and locking themselves out of the house; 2) in terms of teaching so students learning about human error can try to categories this real data in class exercises; and 3) in research as we can learn more about human error but also resilience strategies – I shared our paper on the topic (click here for the paper). The people loved Errordiary as a simple concept for starting debate about human error in an engaging way. Interesting points were brought forward for Errordiary: how to transfer this value to healthcare, whether it would be anonymous for clinical staff, if errors and resilience strategies can be directly linked, if we could test/prove that a wider knowledge of resilience strategies could actually improve performance.

For those doing training, and who are interested in engaging material for spreading the Human Factors word, I pointed them in the direction of Microwave Racing so people can see what a difference the design of devices make. I heard that the Institute of Ergonomics and Human Factors were using this in presentations to school children and it had great feedback. A complementary video that I really like shows the poor usability of some medical device and software design, and the real trouble that users have using it.

In the afternoon workshops I attended the resilience themed events. Both were looking at resilience and high reliability organisations (HRO) at a management/organisational level, which is fine but to the initiated this can fall into a lot of management speak about communicating better, being preoccupied with risk, monitoring, anticipating, etc. etc. They did a good job and it served their purpose in inspiring debate and offering a different approach to traditional forms of safety management. However, it still feels like concrete examples are missing from these talks.  What are the limitations of a resilience view or HRO view? Is there a difference between resilience and HRO? Is there an alternative and what is it? What is the one thing we would recommend people do in their work tomorrow to start to realise these approaches? One interesting idea is that healthcare organisations are constantly resilient and that instances of this should be distilled, celebrated and shared.

I started the day by tweeting that I had forgotten my business cards at home which was my first errordiary tweet of the day… it seems I’ll end it with forgetting my poster on the train from Cambridge to London. I was engrossed with writing this so when I left the train I grabbed my coat and my bag and left it behind. I’ll fill out a lost property form tomorrow but I doubt we’ll be reunited again 😦


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