Tackling human and organisational factors: the human contribution

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This paper by Emma Nunez and Patrick Mitchell examines the role of human factors in tackling the human and organisational factors around patient safety. It includes the key roles of staff and how to develop organisational resilience.

The NHS for many years has concentrated on a system focused solution to errors, while attempting to avoid an individual 'blame culture'. Although this focus has been positive in achieving a more robust understanding of incidents, errors, and their management, the drive for searching out 'system failures' has perhaps been at the expense of identifying the accompanying 'human factors'.

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You are so correct LJ McLean, I have battled this lack of knowledge and therefore understanding for a long time. Often we have no choice but to find others ways to develop understanding in these senior managers. I cracked the problem, I get all Execs to start patient safety rounds, every month they are scheduled with me to visit all the clinical areas they control. Staff were astonished at first, then they discovered they could discuss issues directly with the person who has the power to change things quickly. Everyone was, dare I say, hostile at first, now the Execs are starting go on their own and wouldn't miss a visit. Things have changed so quickly in some areas even I couldn't have imagined the changes that have been achieved. There are Execs who resisted being involved, most realised the benefits and stared rounds, others remain unconvinced but are watching events closely. The Execs have started to understand and suddenly have become change agents. There are other leadership spin-offs but that's another story.
by Christopher Dickinson
Sounds absolutely inspirational. You don't say where you work, or if you have given a name to this initiative. It sounds like it should have one. And is it being written up, so others can see?
by Linda Jane Mclean

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