Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2025_Библиотеки_им_академика_М_И_Перельмана.pdf
PART III
HUMAN FACTORS AND
NON- TECHNICAL SKILLS
129
Surgical First Assistant: The Essentials of Practice, First Edition. Editedby JulieQuick andMarkOwen.
© 2025John Wiley & Sons Ltd. Published 2025 by John Wiley & Sons Ltd.
CHAPTER 11
Human Factors
Ally Ackbarally
1,2
1
Senior Lecturer and Practitioner in Perioperative Practice De Montfort University,
Leicester, UK
2
SFA and Human Factors Institute of Health, Health Policy and Social Care
Research, De Montfort University, Leicester, UK
INTRODUCTION
Human factors as a science when applied to healthcare are important to maintain
patient safety in hospitals, especially during surgery where risks are higher and where
harm to patients and staff can be detrimental. There are many definitions of patient
safety. The NHS (n.d.) defines it as:
… the avoidance of unintended or unexpected harm to people during the provi-
sion of health care. We support providers to minimise patient safety incidents
and drive improvements in safety and quality. Patients should be treated in a
safe environment and protected from avoidable harm.
To help reduce risk and improve patient safety, human factors are now a part of
clinical practice encompassing the management of errors, learning from adverse
events and improving clinical performance and the well- being of the team. Human
factors also take into consideration the complexity of healthcare settings which
includes the science of patient safety, human errors, non- technical skills, system
design and indeed the organisational elements and the environment. Surgery repre-
sents a very complex environment due to the nature of the work and when human
factors are weaved into the work, roles and tasks of the theatre team, it has been
proven to improve patient safety, outcome and team performance (Lee etal.2022).
130 Chapter 11 Human Factors
The internationally adopted definition of Human Factors and Ergonomics (HFE)
is ‘the scientific discipline concerned with the understanding of interactions among
humans and other elements of a system, and the profession that applies theory, prin-
ciples, data and methods to design in order to optimise human well- being and overall
system performance’ (International Ergonomics and Human Factors Association
(IEHFA)2000). Therefore, for the purpose of this chapter, human factors and ergo-
nomics (HFE) as a term will be used throughout.
The operating theatre is a complex microcosm of a hospital system where many
practitioners such as surgeons, anaesthetists and other healthcare practitioners
including surgical first assistants (SFAs) work together as a unit. While all team mem-
bers are working together for the same shared goal, that of patient safety, they each
have their own role and responsibilities to achieve this goal. The operating theatre is
one department in a hospital where you will see teamwork or communication at its
very best, even when the team has to cope with unexpected events. An experienced
and technically competent SFA provides valuable assistance and support to the sur-
geon but when the SFA’s practice is underpinned by the principles of human factors,
safety of the surgery and care will be enhanced as it is firmly accepted that critical
events in operating theatres are mostly influenced by the system and environment
rather than necessarily because of individuals (Carayon etal.2014). This chapter will
focus on HFE concepts and approaches which when understood and applied in prac-
tice will support the safety of patient care and will enhance the performance of the
SFA. More specifically, the discussions will focus on the following aspects:
• Implications of Human Factors
• Patient Safety
• Human Error
• Patient Safety Frameworks
• SFAs Well- Being
IMPLICATIONS OFHUMAN FACTORS
The SFA works in an environment where never events and safety incidents are a
constant threat (NHS England2023). They need to appreciate the impact of the pre-
vailing culture in the workplace and how the environment, tools and technology
influence and impact upon the SFA including interactions with the team. HFE con-
siders three domains: physical, cognitive and organisational ergonomics (see
Table11.1). These can be used to assess the impact on the SFA and ways to mitigate
against them.
Surgical assistance is often performed under pressure but there are various HFE con-
siderations SFAs have to understand and demonstrate within their practice to improve
performance and support safer surgery (see Figure11.1). For example, when individuals
start shouting at each other, a lack of civility is demonstrated and the psychological safety
TABLE11.1 HFE Domains forthe SFA (Adapted fromIEHFA, 2000)
Physical Ergonomic
Definition Impact on SFA Risks Actions
Anthropometry, the
study of human
measurement (e.g.
body size and
shape).
Anatomy and
physiology.
Biomechanics of
the human body in
relation to work
activities.
Concerned with the
physical health and
well- being of the SFA.
Carrying out
repetitive tasks.
Handling heavy
loads in unnatural
positions such as
during joint surgery.
Wearing lead
jackets at the table
for ling periods
while assisting.
Unnatural positions
when assisting.
Risk assessment should
be completed to identify
hazards and reduce
risk. For example:
Micro breaks
Changing position
Use of arm rests when
assisting
Bespoke theatre
footwear
Anti-
fatigue mats
Cognitive Ergonomic
Definition Impact on SFA Risks Actions
The study of mental
process or cognitive
ergonomics.
Concerned with mental
function, processing of
information and mental
workload at the table
which can affect
non- technical skills
such as decision
making an situation
awareness.
Too much information
Fixation on task
Non- recognition of
stress and fatigue of
self and/or the
surgeon and others
situation.
Self- awareness of
stress management
Stress management
training
De- escalation
training
Organisational Ergonomic
Definition Impact on SFA Risks Actions
Optimisation of the
sociotechnical
system of the
workplace.
The impact of the
team, structures,
policies and processes
on the SFA.
Distractions due to
noise.
Long shifts assisting
causing fatigue and
stress
An operating list that
over runs or no break
during list.
Request for quiet
Delegation of some
role and
responsibilities
Review shift
patterns if
impacting on
health and
well- being.
132 Chapter 11 Human Factors
of an individual or other members of the team may be compromised. Psychological
safety is simply a shared mental model or a shared belief that members of the team feel
safe to be open and honest about risks, safety, the freedom to admit to errors without fear
and free to speak when needed (NHS England,2022b). If the SFA does not feel psycho-
logically safe due to fear of blame or a poor supporting working culture, it can have a
cognitive impact on the SFA where their ability to think, reason or decision- making can
all be affected (Lewis2023). Another example is where communication may fail during
a case if there is a perceived or actual hierarchical gradient in the department which
could result in an error if the SFA does not feel confident to speak up.
Hierarchy
Non-
technical
Skills
Tasks and
procedures
Mutual
support
Assertiveness
Civility
Pscychological
safety
Perception
and
awareness
Organisational
factors
Workplace
culture
HALToS
hunger,
anger, late,
tired, other
stresses
Assumptions
FIGURE11.1 HFE considerations that may affect the SFA.
PATIENT SAFETY INSURGERY 133
To help understand HFE, models exist to guide thinking processes and clarity of
thoughts. For example, the SHEEP model (see Figure11.2) can be used to identify the
risk from various levels such as the individual, teams and organisation. When applied
systematically, it can recognise trends and patterns, therefore supporting decisions on
where to prioritise or target (Rosenorn- Lanng and Vaughan2013). The model can also
be applied to explore an incident or near miss and can help uncover variables that
influence human error, hence providing more understanding of what is happening in
the workplace rather than focusing on the individuals.
PATIENT SAFETY INSURGERY
Patients must be at the centre of safety considerations in the operating theatre as
safety is the foundation of patient care (Choi etal.2021; WHO2021). There are many
patient safety initiatives that have been implemented in the operating theatre
including the WHO surgical safety checklist which showed an improvement in com-
munication, safety culture and reduced errors (Lepänluoma et al.2014) and more
recently the introduction of NatSSIPs2which ensures that organisational standards,
processes and performance for safety are weaved within the NatSSIPs 8 standards
(Centre for Perioperative Care (CPOC)2023).
Other initiatives, more specifically, related to surgery have been intrinsic parts of
surgical safety practices such as surgical pauses before critical interventions, for
example, when inserting an implant, checking laterality, removal of organs and tis-
sues and when conducting other specific counts. However, incidences such as sur-
gical never events are not necessarily improving compared to previous years (NHS
England 2023). An explanation for this could be that the healthcare system as a
whole is not necessarily a learning organisation (Akhnif etal.2017). Organisations
are often reactive rather than proactive in dealing with never events and critical inci-
dents which will continue to happen unless organisations learn from these events.
Wu etal. (2021) and the CQC (2022) report a lack of motivation and feeling psycho-
logically unsafe can prevent sharing of such events. There are many ways in which
teams can share their learning such as the Positive Event Reporting Form (PERF)
S – System
H – Human interactions
E – Environment
E – Equipment
P – Personnel
FIGURE11.2 SHEEP model acronym. Source: Adapted from Rosenorn- Lanng (2014)/Oxford
University Press. Photo by Copilot AI design 2024.
134 Chapter 11 Human Factors
tool (Oliver et al. 2020) or Favourable Event Reporting Form (FERF) tool (Chase
etal.2015).
SFAs are trained to an enhanced level of surgical assisting, this implies that they
should also have an enhanced level of knowledge about surgical and organisational
processes, and patient safety protocols. For example, the SFA should follow all ele-
ments of the safety procedure such as the NatSSIPs 8 (see Chapter5).
Hollnagel et al. (2015) identify two approaches to improving patient safety. The
first, Patient Safety I, is a reactive approach starting from when something has gone
wrong before actions are taken. The focus is on the cause of the incident and usually
focusses on individuals. Patient Safety II is a different approach to the first approach
where learning is the primary aim to improve practice. Within this approach, learning
such as team simulation can be used to support learning. Furthermore, SFA education
should have human factor principles embedded in the curriculum supported by simu-
lation training where human factors is assessed to equip the SFAs with those principles.
HUMAN ERROR
We all know the axiom that to err is human (Kohn etal.1999) but not understanding
or not trying to understand the human error in healthcare is negligent. This is because
understanding how an error occurred may prevent the next similar error rather than
focussing on who committed the error. Human errors form a significant part of pre-
ventable incidences in healthcare and unfortunately many incidences occur (see
Chart11.1) and it is also interesting to see how error reporting and errors increased
over the years. Crucially, the WHO believes that up to 85% of errors can be avoided
(WHO2023).
Everyone can make a mistake, even the most competent and skilled practitioners.
SFAs who are assisting in theatres means they are working at the sharp end where if
errors happen, they are considered as active errors. For example, a retained swab is
classified as an active error as it is regarded as the actual event that resulted in harm;
however, latent errors are also contributing factors (Sameera etal.2021). An example
of a latent error is when the wrong patient continues into the anaesthetic room,
despite previous checks. There are many types of human error causations in health-
care such as lapses in concentration, fixation on a task and bystander apathy where
someone thinks someone else will carry out a task or speak up. These cannot neces-
sarily be eliminated by training but improved system design can reduce their likelihood
of re- occurring (Health and Safety Executiven.d.). Very often these errors occur due
to a lack of psychological safety and incivility.
Strategies such as team training and team assessments using TeamSTEPPS 3.0
(Agency for Healthcare Research and Quality 2023) and the OTAS tool (Sevdalis
etal.2009) can be used to design out the risks of errors. SFAs should also be
conscious of other human error instigators such as the ‘Dirty Dozen’ by DuPont
(1997) (See Figure11.3).
Human Error 135
Lack of
communication
Complacency
Lack of
knowledge
Distraction Pressure
Lack of
resourses
Fatigue
Lack of
teamwork
Lack of
assertiveness
Stress
Lack of
awareness
Norms
FIGURE11.3 The Dirty Dozen (Adapted from DuPont1997).
Chart 1: Number of incidents in England, reported by quarter
from Oct 2003 – Jun 2022 (NHS England 2022)
0
Oct –Dec 2003
Apr– Jun 2004
Oct– Dec 2004
Apr– Jun 2005
Oct –Dec 2005
Apr– Jun 2006
Oct– Dec 2006
Apr– Jun 2007
Oct –Dec 2007
Apr– Jun 2008
Oct– Dec 2008
Apr– Jun 2009
Oct –Dec 2009
Apr– Jun 2010
Oct– Dec 2010
Apr– Jun 2011
Oc
t –Dec 2011
Apr– Jun 2012
Oct
– Dec 2012
Apr– Jun 2013
Oc
t –Dec 2013
Apr– Jun 2014
Oct
– Dec 2014
Apr– Jun 2015
Oct –Dec 2015
Apr– Jun 2016
Oct– Dec 2016
Apr– Jun 2017
Oct –Dec 2017
Apr– Jun 2018
Oct– Dec 2018
Apr– Jun 2019
Oct– Dec 2019
Apr– Jun 2020
Oct– Dec 2020
Apr– Jun 2021
Apr–
Jun 2022
Oct– Dec 2021
1,75,000
3,50,000
5,25,000
7,00,000
Incidents submitted
CHART 11.1 Number of incidents reported by in England Between Oct 2003 and June 2022
demonstrating an increase in incidences. Source: NHS England (2022)/Crown copyright/
CC BY 3.0.
136 Chapter 11 Human Factors
PATIENT SAFETY INCIDENT RESPONSE FRAMEWORK
Due to the nature of surgery itself, the nature of the tasks and the sheer volume of
patients operated on everyday make the operating theatre a high- risk environment
and the probability of serious incidences occurring is high. Devlin and Smith (2021)
reported that 60% of all never events reported in the NHS happened in the operating
theatres. Until recently, most incidences were investigated using a root cause anal-
ysis but there are inherent problems in thinking and using root cause analysis only
(Peerally et al. 2017). The introduction of the Patient Safety Incident Response
Framework (PSIRF) by NHS England (2022a) provides a framework which includes
guiding principles and tools to investigate incidents, processes and implement
learning as well as quality and safety improvement strategies (NHS England2022a).
The framework encourages system thinking and service user and staff engagement.
Integral to the framework is the Systems Engineering Initiative for Patient Safety
(SEIPS) tool which is a system- based investigative tool. SEIPS can be used by the
SFAs to reflect and analyse what affects their performance when assisting (see
Figure11.4). It is clear that the SFA’s performance can be affected by a wide range
of systemic factors and while the risk for error increases so too does the risk of
stress, fatigue and burnout.
SFA’S WELL- BEING
A well and healthy SFA will be a safer and a high- performing SFA (Shorrock and
Williams2017; CIEHF2018). One of the ways of achieving this is to embed human
factors strategies into the workplace such as the hierarchy of control model mentioned
by Kelly etal. (2023) where the focus is on designs, barriers, mitigation rather than
only training and education. The environmental and technological designs that support
the individuals in the workplace should also synchronise with the staff rather than
Person
high workload
staff absence
fatigue/stress
Organisation
poor theatre
scheduling
lack of traning
lists over running
Tools and
technology
unreliable
outdated
Tasks
inadequate
training
complex
time pressure
Internal
enviroment
poor skill mix
poor communcation
poor teamwork
External
enviroment
Health Policy
Deparment of
Health
Processes
porcesses
protocols
guidlines
FIGURE11.4 Identification of what could affect SFA performance. Source: Adapted from SEIPS
(NHS England2022).