Enhancing Human Factors to Improve Patient Safety

This week is Patient Safety Awareness Week. The Institute for Healthcare Improvement describes this “an annual recognition event intended to encourage everyone to learn more about health care safety”.  Working with a range of clients across the healthcare sector, we are aware of the value healthcare professionals place on patient safety and the current efforts, in the UK and globally, to ensure standards are improved for the benefit of patients and the workforce.

WPG have frequently worked with Foundation doctors to enhance the non-technical skills needed to ensure patient safety in their practice. However, we appreciate that some of the ‘human factors’ associated with maintaining a safe approach to the delivery of patient care are relevant across a range of healthcare roles. In support of Patient Safety Awareness Week, we wanted to highlight the importance of considering  human factors, in addition to clinical skill, when it comes to patient safety.

How do Human Factors impact Patient Safety?

There’s a great deal of evidence to show that improvements in patient safety must consider both technical and non-technical causes of error. The development of these non-technical skills, for example decision-making, self-awareness and resilience, communication and team-work, can help to reduce the risk of error. Healthcare professionals also gain more insight about their impact on others by developing their skills in these areas.

“Extensive work in high-stakes industries has demonstrated that improving safety is not just about enhancing knowledge or skills, but also concerns the addressing of human factors and poor performance of non-technical skills that can lead to errors.“[i]

Decision-making in healthcare can be understood through attention to individual differences,  human thought processes such as the perception and integration of information, as well as the judgements we make about information. It’s not just the clinical facts that are important, but also the process our minds go through when making decisions.

Why is Examining Decision-Making in Healthcare Important?

Important decisions have to be made every day in healthcare settings, often under stressful or pressurised conditions – Consider your local Emergency Department during a busy night shift; doctors, nurses and other staff are all trying to manage their own competing priorities, whilst also trying to communicate and collaborate to ensure all patients receive adequate attention – that requires a myriad of decisions by individuals and teams that need to be in alignment! Decisions in healthcare are open to scrutiny by others, including the public, as social media and other forums create platforms to share experiences of the healthcare service. The potential outcomes of these decisions can be severe, particularly in a developing culture of litigation. Often tensions can exist between what the right thing to do is, and what feels like the right thing to do – some of the feedback we often hear from doctors concerns the tension between following the ‘rules’.

Decision Making Processes and Pitfalls

A number of models, techniques and ‘decision-trees’ exist to show the complex and varied manner in which we can make decisions as human beings. However, two relatively straightforward and contrasting models of decision-making are the Normative and Descriptive models. These are more commonly referred to as the ‘Rational’ and ‘Intuitive’ approaches to decision-making.

Rational Decision Making is slower, more conscious, effortful, explicit and logical.

Based on analysis, it involves following a series of ‘steps’ to make decisions, for example defining a problem, implementing solutions and monitoring outcomes. Rational decision-making is an ideal standard for decision making based on assurances of objectivity and accuracy. It is preferable for high stakes decisions

Intuitive decision-making is quick, automatic, effortless, implicit and often emotional. 

More appropriate when decisions are less critical but beneficial when time is limited, it is easy to see why many would defer to this approach in order to speed up their decision-making. However, basing decisions on intuition (e.g. pattern recognition), creates an increased risk of error or bias.

More often than not healthcare professionals are making time-critical decisions about patients’ safety and welfare; in reality a rational approach to decision-making is unlikely to be an option. Therefore, with increasing emphasis on efficiency, it is particularly common (and not just in medicine) for people to utilise the mental shortcuts or ‘heuristics’ defined by intuitive decision-making. As well as the efficiency this may achieve, it is important to also recognise the potential pitfalls associated – errors don’t always lead to failure but the consequences of poor decisions where patient safety is concerned can be significant. Some common cognitive biases associated with intuitive decision making include:

  • Anchoring – Giving disproportionate weight to certain pieces of information, especially initial information
  • Sunk Cost – Perpetuating the mistakes of the past, because ‘We have invested so much in this decision that we cannot abandon it or alter course now’.
  • Confirmation Bias – Seeking information to support existing predilections or discount opposing data.
  • Attributional Bias – Attributing particular characteristics due to limited memorable experiences or stereotypes; for example, having a bad experience with a member of the medical team and then forming an unconscious perception that other members of the team will behave the same way.
  • Recency – Tendency to consider or giving undue weight to recent events; also known as ‘hindsight bias’.

Top Tips for Improving Intuitive Decision-Making

  • Reflect on decisions before and after – could your thoughts/perceptions have been distorted in any way?
  • Examine Beliefs – check if the beliefs upon which you have based a decision are reliable facts or evidence
  • Communication & Consultation – discuss your reasoning with others, seek feedback to validate or challenge your rationale; the reasoning behind intuition may become more explicit through discussion.
  • Increase Repetition and Variation of Experiences – try new things and repeated approaches in different contexts; patterns develop from experiences.
  • Learn to recognise and interpret emotions – they provide signals of previous patterns and experiences.
  • Enhance Self-Awareness – emotions are powerful cues and should not be ignored entirely in the context of effective decision-making. However, you need to be attuned to recognising your own emotions and self-aware enough to know their impact; emotions provide signals of previous patterns and experiences.
  • [i] Gordon, M., Darbyshire, D., & Baker, P. (2012). Non-technical skills training to enhance patient safety: a systematic review. Medical Education, 46 (1042-1054).