By Peter Dzendrowskyj
The Chernobyl disaster, the Piper Alpha explosion, the Hillsborough crowd deaths and the Space Shuttle Challenger explosion all involved a breakdown and failure in non-technical skills. These skills, known as ‘human factors’ have long been studied and taught in industries such as aviation and nuclear power. The failure to recognise and address these skills accounts for the vast majority of errors in modern medicine. Every day in every hospital, clinic or outpatient department, an error occurs because of human factors training – wrong notes get delivered, wrong X-rays are ordered, medication errors occur, wrong site surgery happens, patients die unnecessarily – the list is frightening. In Sports Medicine, we assume that because we work with athletes and teams, that we as health professionals are natural team players too. But, most of us realise that this is not always the case.
What are ‘human factors’ in medicine?
The Clinical Human Factors Group in the UK () defines human factors in medicine as “enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings” (1). Essentially, this means everything related to human performance. But humans are unpredictable and along with unpredictability comes uncertainty and unreliability. Individuals will – by definition – react to different situations in different ways. Clinical human factor experts understand this and use these differences to enhance patient care. This dips into the realms of psychology, and personality differences – human factors also encompass the ‘study of teams in their environment’ since optimal outcomes depend on optimal teamwork, both within and among teams. So, often it is positive human interaction that differentiates success from failure in our clinical work.
We assume that we can learn human factors by observing others, but can we really?
This ethereal and somewhat nebulous topic is so often deemed unimportant in medicine. Very frequently it is not included in the already overly-crowded undergraduate and post-graduate curricula of medical education. The assumption is that doctors will be able to automatically interact with individuals and run their teams or will be able to learn the necessary skills by observing and osmosis. This is blatantly not the case. It is estimated that there are approximately a quarter of a million deaths due to medical error each year in the USA alone- equivalent to a Boeing 747 crashing on mainland USA every few days with all those on board dying. The majority of these medical errors happen because of a breakdown in communication (2).
Of 2455 sentinel events reported to the Joint Commission of Hospital Accreditation in USA in 2004, communication failure was the primary cause of error in 70% of cases. Of these events, 75% of these patients died. This is just one example that shows us the importance of communicating well (3). These figures only refer to critical events leading to death – in sports medicine, the number of events leading to sub-optimal treatment options, delays in diagnosis, delays in rehabilitation and return to play are likely to be more pronounced, but this has not been measured at present.
What about ‘human factors’ in sports medicine?
Human factors are vital to every branch of medicine and sports medicine is no exception. The tragic death of Marc-Vivien Foe is an example of a breakdown in these human factors. This talented Cameroonian international football player collapsed on the pitch whilst playing against Columbia on 26thJune 2003. He was thought to have suffered from previously undiagnosed hypertrophic cardiomyopathy and died as a result. His collapse was televised live and watched by millions. The most tragic part of this entire event was that there was no basic CPR, let alone Advanced Life Support, for several minutes after his collapse, despite healthcare professionals being immediately present on the scene. There seemed to be a breakdown in communication and in non-technical skills by medical staff on the pitch. There is little doubt that those individuals involved were trained and knew how to perform CPR and defibrillate in a timely fashion, but for some reason they did not “join the dots” and do so.
Unfortunately, this is similar to the desperately sad story of Elaine Bromiley who died after a routine anaesthetic went wrong. Three experienced Consultant Anaesthetists were present but were not working through a “can’t intubate, can’t ventilate” algorhythm adequately (4,5). Let’s put this up against the teamwork, communication and situational awareness shown by the healthcare professionals who ran onto the pitch and started CPR on Fabrice Muamba when he suffered a cardiac arrest playing for Bolton Wanderers against Tottenham Hotspurs in March 2012 (6). What makes one team work well and another perform sub-optimally depends on education around human factors, and is something we need to all seriously consider and work to improve.
Which human factor skills are important?
They aren’t rocket science! In her excellent book “Safety at the Sharp End”, Rhona Flin lists them as:
- Team working
- Stress management
- Situation awareness
- Coping with fatigue (7)
Step 1: Let’s recognize that we need to make concrete efforts to improve our human factor skills
How often have we explained something to a patient, or a professional colleague, and at the end of the conversation have left with very different conclusions to the same discussion? How many times have we made a transcription error – whether it be writing in the wrong notes, transcribing the wrong X-ray request or a medication error for example. We need to recognise that we as doctors are poorly trained in these soft skills that are vital to good clinical outcomes. Once recognised, the challenge then becomes actually doing something about this inadequacy. Whether it be in clinic, in consultation with patients, in the operating theatre or elsewhere, a breakdown in one of these skills is associated with error. Being able to recognise that we need to improve our own human factor skills is the first step to actually doing so.
In Part 2 of this blog, I’ll elaborate on Rhona Flin’s human factor skills. Specifically on how we can improve the way we communicate, improve our situational awareness skills and, touch on teamwork and leadership skills.
Peter Dzendrowskyj is a dually accredited Intensivist and Anaesthetist who calls both UK and New Zealand home – although he has been working at Aspetar Hospital in Qatar for the past few years. He is actively involved in education and teaching. His particular interests are in the treatment of sepsis and burns, clinical teaching and education, medical simulation, human factors and clinical leadership. Email: firstname.lastname@example.org
- . Accessed January 4th 2019
- Makary MA, Daniel M. Medical error—the third leading cause of death in the US. British Medical Journal, 2016; 353:i2139. doi: 10.1136/bmj.i2139
- Joint Commission on Accreditation of Healthcare Organizations. Sentinel event statistics, June 29, 2004, Available at: www.jcaho.org/ accredited+organizations/ambulatory+care/sentinel+events/ sentinel+event+statistics.htm
- Laerdal Medical AS. Just a routine operation. Available from:
- McClelland G, Smith MB. Just a routine operation: a critical discussion. Journal of Perioperative Practice 2016; 26; 5: 114-117
- Ferguson E. 78 minutes in the life (and near death) of Fabrice Muamba.https://www.theguardian.com/football/2012/mar/25/muamba-collapse-minute-by-minute
- Flin R, O’Connor P, Crichton M. Safety at the Sharp End. A guide to non-technical skills. Ashgate publishing. Published 2008.