We are extraordinarily grateful that awareness of human factors (HF) has been growing in the healthcare community. For example, the FDA’s inclusion of HF requirements in its 510(k) licensing processing was a landmark event recognizing that attention needs to be paid to how the design of medical devices influences the likelihood of error.
However, in our work applying and teaching the philosophy of HF, we have found that it sometimes requires clarification.
First and foremost, the term “human factors” is a bit of a misnomer. This term implies that this is a discipline concerned solely with humans. However, it is important to understand that HF is really the study of humans in context. Rather than a pure study of human abilities (e.g., memory, attention, reaction time, physical-lifting limits), HF is an attempt to understand how human strengths and limitations are exemplified by the world around them. Unlike a tangible medical device that one can point to, HF deals with intangible qualities. It studies how well policies, processes, technologies, and humans fit together in delivering safe and efficient care. The routes leading to patient harm far exceed those that lead to caregivers’ original intention. Medication administration for example, can be affected by the physical design of hospitals, shift schedules of hospital staff, the design of pharmacy software, lighting at the bedside, and infinitely more variables. These are all system factors that influence patient safety, and they are anything but limited to human qualities.
As a result, we always cringe when, in a conversation, someone alludes to a “human error” and point to “human factors people” to deal with them. This is one of the reasons we named our team HumanEra—a deliberate play on “human error.” We want to represent a new era in healthcare, where we treat people with respect, recognize and forgive our limitations, and, as a result, improve the conditions for our care providers and our patients.
We would like to challenge you to look at HF as a discipline concerned with “system factors,” with a particular focus on those points where humans are involved. By acknowledging that human beings make mistakes, we are free to absolve ourselves of a paradigm of “human error” and look toward improving the system factors that help humans detect and correct errors.
At the AAMI 2013 Conference & Expo, we will be leading a two-part workshop sharing our systems perspective regarding HF in healthcare. We want to encourage an in-depth discussion about HF and hope that going forward attendees will start looking critically at these “system factors.” We plan to offer you concrete lessons, ideas, and tools to help you champion HF in your own work.
It has been said that walking is a series of controlled falls. Let’s do the same as a collective group, working to improve safety in healthcare.
Here’s to walking forward.
Christopher Colvin, a human factors analyst, wrote this post with colleagues at HumanEra.