A scientific field that has benefited aviation for 50 years is only just beginning to be recognised and valued in a medical context, where its application could prevent a vast amount of injuries and save countless lives. It’s incredible to think that statistically you’d have to fly on a plane for 36,000 years before you’d incur a serious injury due to a preventable error. But, if that serious injury then landed you in hospital, you’d have around a 1 in 300 chance of death due to a preventable error. Why?
In March 2013 the BBC aired an episode of Horizon entitled ‘How to avoid mistakes in surgery‘ where Dr Kevin Fong, an Anaesthetic Lead at UCLH, highlighted a surgical case study which showcased how small and simple errors align to result in a preventable death. He then investigated systems and processes used in other safety critical industries which could be applied in the operating theatre to prevent such situations.
Throughout the programme Dr Fong touches on the training in the fire service, the teamwork of an F1 pit crew and the checklists used in aviation; all are safety critical industries and all use human factors within and beyond the examples he provides. He then demonstrates how lessons learned in these cases can, and have, been applied in and around operating theatres, with astounding results.
It still begs the question; with such remarkable results, why the lack of human factors in healthcare?
Dr Ken Catchpole (co-author of the study into F1 pit-stop and aviation models for use in patient handover) points out a few of the contributors to the lack of Clinical Human Factors in his TEDx talk in Santa Monica last year, it is definitely worth a watch here. He talks through resistance from doctors and nurses, easily solved drug packaging design, the surgical hierarchy, not discussing ‘near misses’ and other basic examples where applying human factors would make a huge difference.
Figures from Patient handover from surgery to intensive care: Using Formula 1 pit-stop and aviation models to improve safety and quality (Catchpole et al. 2007) – Image credit: clinicalhumanfactorsgroup.com
Despite factors such as proving its worth repeatedly in other industries, significant recommendations from the chair of an NHS trust (Sir Stephen Moss; his report can be found here), and impressive results when applied within a clinical setting, human factors still does not have its rightful place on the clinical map. Healthcare, as a whole, is staring into the face of huge challenges, however, IEC 62366 and current FDA direction ensure consultants such as I can at least promise a human-centred process that will ensure medical devices and equipment are safe and easy to use; a satisfying step in the right direction. Meanwhile, I look forward to the day the healthcare industry recognises clinical human factors for what it’s worth. Lives.