Of humans, factors, failings and fixations

Yentis, S.

doi:10.1111/j.1365-2044.2009.06018.x

Cited by 13 publications

(7 citation statements)

References 13 publications

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“…Other examples include the lag in systematic use of usability techniques and ergonomic principles in healthcare technology [79][80][81] . There are few avenues to report design or usability problems once technology is fielded, and there may be attraction in heroic acts and creative workarounds necessary to make technology work [82] .…”

Section: Autonomy and Professional Identitymentioning

confidence: 99%

Second victims, organizational resilience and the role of hospital administration

Santomauro

Kalkman

Dekker

2014

JHA

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Second victims are practitioners involved in an incident that (potentially) harms or kills somebody else, and for which they feel personally responsible. Professional culture and the psychology of blame (and shame) influence how second victims are viewed and dealt with. This paper reviews the status of second victimhood in healthcare -both its symptomatology and organizational responses. Then it considers the problematic nature of "human error" in healthcare and sets this against the psychological backdrop of healthcare professions, seeking cultural-historical explanations in assumptions of actor autonomy and professional identity. It concludes by drawing links between the psychological resilience of the individual practitioners involved in an incident and the resilience of an organization's safety culture.

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Section: Autonomy and Professional Identitymentioning

confidence: 99%

Second victims, organizational resilience and the role of hospital administration

Santomauro

Kalkman

Dekker

2014

JHA

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“…‘Human factors’ refers to the study of environmental, technical, organisational, psychological and physiological influences on human performance. The role of human factors in the safe and efficient delivery of anaesthesia is recognised, illustrated by a recent editorial in this journal .…”

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confidence: 99%

Human factors in the development of complications of airway management: preliminary evaluation of an interview tool

et al. 2013

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Summary The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) analysed reports of serious events arising from airway management during anaesthesia, intensive care and the emergency department. We conducted supplementary telephone interviews with 12 anaesthetists who had reported to NAP4, aiming to identify causal factors using a method based on the Human Factors Investigation Tool (HFIT). We identified contributing human factors in all cases (median [range] 4.5 [1–10] per case). The most frequent related to: situation awareness (failures to anticipate, wrong decision) (nine cases); job factors (e.g. task difficulty; staffing, time pressure) (eight cases); and person factors (e.g. tiredness, hunger, stress) (six cases). Protective factors, such as teamwork and communication, were also revealed. The post‐report HFIT interview method identified relevant human factors and this approach merits further testing as part of the investigation of anaesthetic incidents.

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“…Fixation error, that is, remaining focussed on one initial diagnosis without considering others when treatment appears to be failing, is an ever-present danger in managing complications and crises (Yentis 2010) and has been commented on before in the context of the Confidential Enquiry into Maternal Deaths (Lewis, Cantwell et al 2011). It is best avoided by repeated instances of 'standing back', during the event, and reviewing and recapping critical incidents including deaths, especially with other team members.…”

Section: Hypoventilation During or After General Anaesthesiamentioning

confidence: 99%

Cardiac disease in pregnancy

Steer¹

2020

Oxford Textbook of Obstetrics and Gynaecology

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Cardiac disease has become the single most important cause of maternal death in the United Kingdom and other developed countries over the last 30 years, mostly due to acquired heart disease secondary to women having their pregnancies later in life. The main causes of mortality are myocardial infarction/ischaemic heart disease (one-third) and cardiomyopathy (a further third). The remaining deaths are mostly associated with rheumatic heart disease, congenital heart disease, and pulmonary hypertension (about 5–10% each). Pregnancy represents a challenge to women with impaired cardiac function because of the cardiovascular changes associated with the increase in blood supply to the uterus and placenta. Preconception counselling is vital and should cover the risk of mortality, morbidity, and the increased rate of preterm birth and fetal growth restriction in affected women. Antenatal and intrapartum care needs to be planned by a multidisciplinary team and delivered by staff with appropriate expertise.

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Of humans, factors, failings and fixations

Cited by 13 publications

References 13 publications

Second victims, organizational resilience and the role of hospital administration

Second victims, organizational resilience and the role of hospital administration

Human factors in the development of complications of airway management: preliminary evaluation of an interview tool

Cardiac disease in pregnancy

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