Human Factors and Patient Safety

The assignment emphasizes the crucial role of human factors in healthcare settings, including communication, effective teamwork, and leadership. It suggests that proper evaluation and monitoring of healthcare professionals' activities, along with initiatives to develop their skills and knowledge, are essential for maintaining a safe culture. The importance of these factors is illustrated through a case study where inadequate communication and teamwork led to a patient's suffering. The assignment also references various studies and research papers that support the significance of human factors in healthcare.

Running head: HUMAN FACTORS IN PATIENT SAFETY
HUMAN FACTORS IN PATIENT SAFETY
Name of the student;
Name of the university:
Author note:

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HUMAN FACTORS IN PATIENT SAFETY
Human factors are considered as the organizational, environmental and job factors along
with different human and individual characteristics that affect the health and safety at the
workplace and influence behaviors of individuals at work. Communication and effective
leadership skills of the head nurses have huge importance as they are directly associated with the
wellbeing of the patients and their family members (Carayon, 2016). These human factors have
influence on another factor called the safety culture. The safety culture of an organization can be
considered as the product of individual as well as group values. It also comprises of proper
attitudes, competencies and perceptions of nurses that along with proper patterns of behavior
ensure proficiency and safety management successfully (Carayon et al., 2014). The assignment
will mainly show how communication error and failure of proper leadership will result affect the
safety culture of the organization and hence patient safety is affected.
A patient was transferred from the emergency ward to the rehabilitation ward after she
was admitted to the former following an incidence of stroke. The patient named Mrs. Samantha
(name changed) was 65 years old. She was suffering from type-2 diabetes. She was also
suffering from obesity that had limited her movements. While she was having a walk in her
garden, she suffered a stroke that made her fall flat on the ground. After admitting to the
emergency ward, it was seen that she had suffered a fall that had affected her knee leading to
swelling. She also had many bruises all over her body that were bleeding. She was immediately
attended and treated with care. The physician on charge had advised for her transfer to the rehab
center where she needs attendance from physiotherapy, speech therapy, diabetes educator and
proper care of the nursing professionals. After her transfer to the rehabilitation center, her
condition began to deteriorate which was quite shocking to her family members and doctor in
charge. The care coordinator of the team was asked for justification where he stated a number of

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facts that resulted in this situation. It was seen that the nursing professionals had complex issues
that affected their communication. The junior and the senior nurses did not communicate with
each other properly for which medication error took place in case of the patient. Although the
effect of the medication error was nullified but the patient had become anxious which had
affected her health. Ineffective communication also existed between the healthcare professionals
and it was evident from the fact that both the physiotherapist and the speech therapists arrived at
the same time in the patient’s cabin that resulted in a conflict about who would be attending the
patient. Such a situation resulted in stress among the patient who thereby complained this to her
family members. The care coordinator failed miserably to properly lead the multidisciplinary
teams. He was unsuccessful in developing a working climate where members trusted on each
other and there was good relationship and bonding among the members. Moreover, as the care
coordinator did not encourage a feedback giving and receiving session, the healthcare
professionals never got a scope of sharing their concerns and issues (Diller et al., 2014). They
were highly demoralized and suffered from stress and fatigue. One of the issues also noticed was
that the healthcare specialists and the nursing professionals never had meetings together where
they could discuss the health of the patient, her present situation, new care requirements of the
patients, suggestions of the others and many others. One of the main activities of the
multidisciplinary team is to discuss their concerns and suggestions together and collaboratively
come to a decision-making situation. This had been the result of improper leadership of the care-
coordinator. This is because he failed to conduct team sessions and could not lead his team
properly (Proctor & VanZandt, 2018). Therefore, ineffective communication and improper
teamwork leadership are the two human factors that resulted in affecting patient safety. It was
also noticed that carelessness of the healthcare professionals, their internal complexes and

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distrust over each other are mainly the results of ineffective communication. Their
unprofessional approach, developing disappointments against the leaders and their stress-fatigue
are mainly the result of ineffective leadership where the leader could not successfully guide the
members and inspire them to provide the best patient care. Therefore, both the factors had been
in turn responsible for affecting the safety of the patient.
Organizational safety culture was also found to be very poor which contributed to the
suffering of the patient and discouraged the healthcare professionals to develop proper healthcare
interventions for assuring safety of the patients. Researchers are of the opinion that every
healthcare organizations should develop an organizational culture where it becomes easier for the
nurse to do the right things and difficult for the nurse to do the wrong thing (Dekker, 2016). The
healthcare organizations should develop a safety culture such that the workforce and the design
processes mainly focus on a clear goal. This goal would mainly be dramatic improvement in the
reliability as well as the safety of the care process. The authority of the healthcare organization
was also found to be responsible for poor health of the patient, as they never paid importance of
maintaining a safety culture in the organization. When evaluations of their activities are done, it
was seen that the healthcare authorities did not take any initiatives to assess the current safety
culture performance of the healthcare staffs (Mosadeghrad, 2014). Therefore, the ineffective and
careless practices of the healthcare professionals became evident. They also did not collect and
analyze data which could be used for targeted improvements. They also did not make reporting
transparent and did not use the adverse events for opportunities step learn and improve instead of
punishments. This fear resulted the healthcare professionals to keep silent and do not report any
medication errors and similar others. They did not have proper policies that could be used by the
healthcare professionals to support the culture of safety and report adverse events. Team based

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training on the safety culture was not encouraged by the authorities and all these resulted in lack
of the organizational safety culture.
Communication is extremely important in healthcare organization to ensure workplace
efficiency that ensures safe delivery of healthcare and hence better quality lives. Communication
can result in gathering effective knowledge among the healthcare professionals, helps in
developing relationships, establishment of predictable behavioral patterns and many others. It is
also urgent for proper leadership and coordination among the teams (Biddison et al., 2016).
When effective communication is not present among the healthcare professionals, it may lead to
a number of issues like improper information delivery during shifting of patient handovers, poor
quality information recorded in patient files, case notes and incident reports (Wick et al., 2015).
Improper communication also inhibits junior nurses from speaking up and there remain
difficulties in transmitting information within and between large organizations. In case of the
case reported, it was seen that due to absence of proper communication and information sharing,
the physiotherapist and speech therapist had arrived for providing service to patient at the same
time. Had the members of the multidisciplinary teams communicated effectively among each
other, such situation would not have arisen (Dicuccio, 2015). Moreover, if the junior and the
senior nurses communicated effectively among themselves, there would have been no birth of
complexes. They juniors could have asked for help from the senior nurses in crucial situations
and the chance of making medication errors by the junior nurses in case of the old patient could
have been prevented.
Team leadership is mainly conducted by team supervisors who has the responsibility of
leading and managing a small group of people who would work together to achieve a common
goal by maintaining safety procedures. Researchers are of the opinion that supervisory safety has

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been found to be associated with the decrease of a number of minor accidents. It also helps in
positively influencing the safety climate perceptions of the workers. Transformational leadership
behaviors of supervisors are found to be related with fewer occupational injuries (Suttcliff et al.,
2016). The leaders are mainly responsible for guiding the team members in their activities in
ways by which they can meet the organizational objectives. They should inspire their
subordinates to develop effective teamwork and thereby bring out the best collaborative output.
When multidisciplinary teams exhibit a collaborative approach, it ensures patient satisfaction and
safety (Ghaferi & Dimick, 2015). As the care coordinator who is the leader of the team did not
posses proper leadership traits, therefore the teamwork suffered massively. He did not stress on
developing proper bonds among the members and did not arrange for any feedback sessions.
Researchers are of the opinion that when suggestions, feedbacks and concerns of subordinates
are taken in consideration, they feel respected and owned by the organization. This has positive
impact on job satisfaction and therefore prevents development of stress and fatigue. As
constructive feedback sessions among the members were not arranged, they could not trust each
other and develop bonding. This led to the development of negative feelings among each other
that affected teamwork (Ammouri et al., 2015). Hence, patient safety was compromised in the
mentioned case study.
From the entire discussion above, it was seen that human factors like communication and
effective teamwork leadership are very important in healthcare sectors. Healthcare professionals
should focus on gaining knowledge about the advantages of communication and effective
teamwork and leadership so that they can provide undisrupted service to their clients.
Organizational safety culture also plays an important role in maintaining patient safety. Proper
evaluation and monitoring of the activities of healthcare professionals and establishing initiatives

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to develop their skills and knowledge are responsibility of the higher officials to ensure safety
culture. Had the healthcare professionals and healthcare authorities of the healthcare center had
maintained and conducted such activities, the patient would not have suffered. In place, she
would have got safe care from the professionals.

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References:
Ammouri, A. A., Tailakh, A. K., Muliira, J. K., Geethakrishnan, R., & Al Kindi, S. N.
(2015). Patient safety culture among nurses. International nursing review, 62(1), 102-
110.
Biddison, E. L. D., Paine, L., Murakami, P., Herzke, C., & Weaver, S. J. (2016).
Associations between safety culture and employee engagement over time: a
retrospective analysis. BMJ Qual Saf, 25(1), 31-37.
Carayon, P. (Ed.). (2016). Handbook of human factors and ergonomics in health care and
patient safety. CRC Press.
Carayon, P., Wetterneck, T. B., Rivera-Rodriguez, A. J., Hundt, A. S., Hoonakker, P.,
Holden, R., & Gurses, A. P. (2014). Human factors systems approach to healthcare
quality and patient safety. Applied ergonomics, 45(1), 14-25.
Dekker, S. (2016). Patient safety: a human factors approach. CRC Press.
DiCuccio, M. H. (2015). The relationship between patient safety culture and patient
outcomes: a systematic review. Journal of patient safety, 11(3), 135-142.
Diller, T., Helmrich, G., Dunning, S., Cox, S., Buchanan, A., & Shappell, S. (2014). The
human factors analysis classification system (HFACS) applied to health
care. American Journal of Medical Quality, 29(3), 181-190.
Ghaferi, A. A., & Dimick, J. B. (2015). Understanding failure to rescue and improving safety
culture. Annals of surgery, 261(5), 839.

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Mosadeghrad, A. M. (2014). Factors influencing healthcare service quality. International
journal of health policy and management, 3(2), 77.
Proctor, R. W., & Van Zandt, T. (2018). Human factors in simple and complex systems. CRC
press.
Sutcliffe, K. M., Paine, L., & Pronovost, P. J. (2016). Re-examining high reliability: actively
organising for safety. BMJ Qual Saf, bmjqs-2015.
Wick, E. C., Galante, D. J., Hobson, D. B., Benson, A. R., Lee, K. K., Berenholtz, S. M., ...
& Wu, C. L. (2015). Organizational culture changes result in improvement in patient-
centered outcomes: implementation of an integrated recovery pathway for surgical
patients. Journal of the American College of Surgeons, 221(3), 669-677.