Clinical Communiqué Volume 6 Issue 1 March 2019
Download PDF: Clinical Communiqué March 2019 Edition
In this edition
Case #1 WITHOUT A TRACE
Case #2 A SHADOW OF DOUBT
Expert Commentary USING A HUMAN FACTORS AND SYSTEMS LENS TO VIEW WHY THINGS SOMETIMES GO WRONG (BUT OFTEN GO RIGHT)
Welcome to the first edition of the Clinical Communiqué for 2019. In this edition, we discuss fixation error, the phenomenon whereby a person or group falls into a pattern of thinking that there is only one possible explanation. This can take on several forms, including task fixation on a procedure, or diagnostic fixation to the exclusion of other possibilities, as unfortunately demonstrated in the two cases presented. The first case sees hospital staff fixate on machine malfunction as the cause of abnormal physiological readings; while in the second, a number of visual and verbal cues lead staff to erroneously fixate on one diagnosis, rather than explore other viable differentials.
We follow these case summaries with a commentary written by two leading experts in the field of human factors. Dr Miranda Cornelissen is a Senior Project Officer with the Incident Response Team in Safer Care Victoria. Dr Cornelissen has a PhD in Accident Research and Human Factors from Monash University and a Master of Science in Cognitive Psychology and Human Factors from Maastricht University in the Netherlands. She has over 13 years of experience applying system safety and human factors principles in transport, defence, emergency management, and more recently in health.
Our other expert is Dr Julia Pitsopoulos, a member of the Safer Care Victoria Academy and a Founding Director of HFRM, established in the UK in 2007. With a PhD in Organisational Psychology and 20 years’ experience in risk and safety management roles, Dr Pitsopoulos has a successful track record in taking a human-centered, systems approach to building strong safety performance and managing human risk. She has worked across a variety of sectors including transportation, energy, defence and manufacturing, and now brings her extensive experience to health.
Human factors, the study of how humans interact within a system, has become increasingly sophisticated, influencing patient safety improvements and learning from error. The ability to view health events through a human factors lens and identify the sociotechnical systems within which clinicians work is an invaluable one. Cognitive bias, attentional resources, situational awareness, and environmental redesign, are just a few of the important terminologies that have entered the lexicon of patient safety reviews and health educational frameworks. The salient commentary in this edition provides an opportunity for clinicians to hear from two human factors experts who bring their skills from other fields to the extraordinarily complex and high-risk industry that is health care. They outline the importance of a safety culture and systems in reducing patient harm, and provide several key human factors resources for further reading.
Just as it is necessary to resist a temptation to fixate on a task or thought, it is also imperative to avoid the tendency to look to humans as the source of all error. Rather, humans are adaptable creatures trying, and generally succeeding, within complex systems. The study of human factors can help clinicians succeed more often within those systems. The focus on the importance of human interaction was identified by the father of the child [AM] featured in this edition, when he graciously remarked at his son’s inquest, “In many ways we see it as our responsibility to ensure [AM’s] loss was not in vain. We hope that there are lessons to be learned not just about avoiding tragedies in the future but also about love in general and the importance of humanity and the sense of community”.
It is said that human factors engineering seeks to identify and promote the best fit between people and the world within which they live and work. A human factors approach views humanity in the context of community, which is key to ensuring that the lessons are being learned.