Human factors, or ergonomics, are an evidence-based science that considers how external factors and personal circumstances influence the reason an event happens (Abildgren et al, 2022).
The importance of human factors in veterinary medicine
Human factors have frequently been studied in professions where mistakes can have disastrous consequences, such as the aviation industry and human medicine, and is now being considered more in veterinary medicine. Understanding human factors enables further safety procedures to be put in place, reducing the risk of negative patient outcomes, while also protecting clinicians from ‘second victim syndrome’. Marmon and Heiss (2015) describe second victim syndrome as the negative impact an adverse patient event that occurs as a result of human error can have on the wellbeing of the practitioner involved.
This can manifest in the form of anxiety, guilt and a loss of confidence, ultimately leading to diminished patient and clinician welfare and an increased risk of mistakes occurring. It should be noted that incidents rarely occur because of one singular failure, but rather as a result of an accumulation of multiple compounding factors.
Delivering anaesthesia
The most obvious human factors that influence the safe delivery of anaesthesia are those which relate directly to the anaesthetist involved in the case. These are often referred to as non-technical skills and encompass that person’s behaviours, such as decision-making, social skills, task and time management, and stress management while they are working (Flin et al, 2010).
Stiegler and Tung (2014) explain how anaesthesia, compared with other specialities, requires a lot of complex, fast-thinking decisions, which without the appropriate skills leave the anaesthetist susceptible to errors. An example of this is the use of heuristics, which Whelehan et al (2020) defined as the use of shortcuts when making clinical decisions, based on experience and confidence.
This can be a useful skill in the correct context; however, factors like overconfidence and the bandwagon effect can lead to heuristics being used inappropriately. Runciman et al (2005) recommended the use of algorithms when issues arise within the operating theatre, providing practitioners with evidence-based protocols in critical and time-sensitive conditions. In their study, the authors created 24 algorithms for the anaesthetist to follow in specific scenarios and found that with appropriate training, they were a useful guide to supplement a clinician’s instinct.
Task management and situational awareness
Task management is another non-technical skill that can have a huge impact on the safe delivery of anaesthesia. Anaesthetists are frequently multi-tasking when monitoring patients under anaesthesia; they are observing the patient and their different parameters, ensuring all monitoring and anaesthetic equipment is working correctly, paying attention to the procedure and what the surgeon is doing to anticipate changes in their patient, among others. Should issues arise with one or more of these components, the anaesthetist must have the skills to prioritise tasks in the best interest of the patient. To do this, they must have good situational awareness, which is the interactions between the anaesthetist, the patient, the team and the environment, and how these can change throughout the procedure (Fioratou et al, 2010).
One of the most influential human factors impacting the safe delivery of anaesthesia is teamwork. Sevdalis et al (2012) explain how good teamwork is made up of multiple components: communication, leadership, coordination and effectiveness.
Communication breakdowns
A communication breakdown can be either intentional or unintentional (Herlehy, 2011), but both can lead to disastrous consequences. Unintentional communication breakdowns include illegible handwriting, language barriers, insufficient handovers between team members and other honest mistakes. These issues can usually be easily rectified with some simple changes to procedures, such as digitising paperwork and following standardised handover protocols.
Intentional communication breakdowns come from intentionally withholding information, whether this be because of a lack of confidence, a lack of trust within the team or rude or disrespectful team members where open communication is not welcomed. This may result in patient outcomes being compromised if staff are not willing to speak up when issues arise.
Leadership and communication
Leadership is an important skill that closely relates to communication. Larsson and Holmstrom (2013) assessed the skills that contribute to a good anaesthetist, and found that having clear, direct communication with the team, especially in the form of an action plan discussion before anaesthesia, was valued by team members. They encouraged remaining calm in critical situations, but also being able to use a direct leading style to take responsibility for a situation. Should complications arise during anaesthesia, not having a clear leader to take charge and make final decisions is likely to have adverse effects.
External factors
Consideration must also be given to contributing factors outside of the operating theatre, such as workload, staffing levels and rota management, as these can all impact the performance of an individual. In a study looking at anaesthetists’ attitudes towards safety within the operating theatre, Flin et al (2003) confirmed that 83% of anaesthetists felt that fatigue and stress levels impacted their work quality, and 66% believed that their work was affected by personal issues. While it is human nature to be influenced by emotions on occasion, the importance of having an awareness of how this may impact on care provided cannot be underestimated, and additional safety mechanisms should be put in place.
To combat some of these potential issues, there are now a number of well-recognised solutions that aim to decrease the risk of adverse patient events as a result of human factors.
Surgical safety checklists
One of these safety mechanisms is a surgical safety checklist, of which the most commonly used is the World Health Organization (2009) Surgical Safety Checklist (Figure 1). It is made up of three different sections, encouraging users to pause pre-induction, pre-incision and at the end of surgery, before leaving the operating theatre. The pre-induction checklist includes confirming patient identity, procedure and consent, whether all surgical and anaesthetic equipment has been checked, and if there are any issues foreseen during induction. The pre-incision checklist then asks everyone in the theatre to introduce themselves with their name and role, and whether they anticipate any critical events. Finally, the post-operative section covers equipment counts, and whether there are any specific concerns for the recovery period.
Completing these questions aims to decrease the risk of problems relating to equipment, such as a closed adjustable pressure limiting valve, a broken flow meter or unsterilised equipment. Providing the team with the opportunity to introduce themselves and their roles, as well as their anticipated concerns, also aids in promoting open and direct communication, especially in large practices where it may not always be the same group of people in theatre. McMillan (2014) felt that one obstacle to implementing these checklists in practice was compliance and that one checklist may not suit all requirements. However, the checklist can be modified to individual team needs and, with time and patience, can be implemented successfully.
Incident reporting platforms
Another available resource to reduce the risk of adverse events is the use of incident reporting platforms. These are forms, usually digital, that a staff member can complete when errors occur, or nearly occur. They can be completed anonymously. They commonly include questions such as what happened, what is the level of harm to the patient and whether there are any contributing factors. By reporting these issues, common themes can be spotted, and protocols put in place to reduce their incidence.
Creating a learning culture
The platforms are invaluable learning tools and create the opportunity for discussion, but can only be successfully implemented in environments with a no-blame culture (Oxtoby, 2018). Robinson et al (2022) explain that moving to a learning culture encourages not to accept human error as the sole cause of an incident, and to concentrate on the improvement of patient welfare when reporting adverse events, rather than taking it personally. Similarly, morbidity and mortality rounds are an ideal opportunity to discuss adverse patient events. McMillan and Lehnus (2018) advised that creating a positive atmosphere where anaesthetists can reflect on their own involvement in cases and any contributing factors, without fearing punishment, will encourage the team to find potential solutions as well as increase the frequency of incident reporting.
Guidelines for reducing adverse events
A working party of human anaesthetists recently created guidelines on reducing adverse patient events caused by human factors, based on some of the most commonly seen causes. Kelly et al (2023) advised anaesthetists to be involved with the design of medical equipment and packaging of medications at an early stage. By taking into account the perspective and concerns of anaesthetists who use the equipment day to day, the manufacturers can make adjustments to the design to reduce the risk of errors.
Kelly et al (2023) also highlighted the importance of education. They suggested providing training to anaesthetists on non-technical skills and the impact of human factors, both so they have these skills themselves and to create a more open, communicative atmosphere with regards to case discussions and investigations. The guidelines also advise creating learning opportunities from situations that went well, rather than focusing purely on near misses or negative outcomes.
Conclusions
In conclusion, multiple human factors can impact the safe delivery of anaesthesia. These factors may be personal, such as the anaesthetist’s non-technical skills, including task management and decision-making, and how they work within a team. Communication and leadership qualities within a team are among the most commonly reported contributing factors in adverse patient events. Consideration must also be given to external influences, such as staffing, rota management, equipment availability and workload. A number of resources are available to combat these issues, including incident reporting platforms, surgical safety checklists and morbidity and mortality rounds. However, to be utilised to their full potential, these require a positive, blame-free culture.