Impact of Human Factors on Healthcare Safety

This assignment delves into the crucial role of human factors in ensuring patient safety within healthcare settings. It examines various human factors frameworks, such as SEIPS 2.0 and the Human Factors Framework for Understanding Adverse Events, to analyze how they contribute to identifying and mitigating risks. The assignment also considers the influence of organizational culture on patient safety and explores research findings on the psychological impact of medical errors on healthcare professionals.

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Running head: SURVEILLANCE AND DISASTER PLANNING
Surveillance and Disaster Planning
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Introduction
Human factors is a multidimensional field of learning getting significant inputs from
engineering, psychology, statistics, operations research. The emphasis of this subject is on
elements of cognition, perception, engineering and empiricism. The human factor is the
prime tool for understanding best practice management of process design and system since it
promotes abilities and competencies of humans in a certain workforce. Human factors are of
chief importance in the healthcare domain since the professionals caring for other are
susceptible to unmonitored high workloads that are indirectly and directly related to the scope
of practice and role of the professional (Gurses et al., 2012). The standpoint taken in this
regard for the present paper is that “identification of the impact of a human factor on the
quality of care delivery and functional performance of healthcare organisations is pivotal for
the promotion of better work environment and patient outcomes.”
The present paper is a critical analysis of literature existing on human factors related
to work performance. The aim of the paper is to compare between literatures and highlight
the similarities and dissimilarities between different findings. The main content of the paper
is divided into two sections; identification and description of human factors related to work
performance, and critical analysis of the association between human factors and quality and
safety in health care.
Identification and description of human factors related to work performance
A number of human factors drive the quality of care in a manner that is noteworthy.
The report of Australian Institute of Health and Welfare (2016) point out that the quality and
safety of care delivered to patients in different healthcare systems in the country has been
drawing attention of the public health organisations as better services are expected for
meeting the rising demands of the population. As per the report, the key focus is on the

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service providers who have deviated from delivering the optimal quality care to the patients.
The report summarised the information on safety and quality issues pertaining to care
services provided. The indicators of hospital safety and quality are healthcare-associated
infections, adverse events in hospital, unplanned hospital readmission rates, falls leading to
patient harms and patient satisfaction and experience. Depending on the results of the
evaluation of these indicators, one can come to the conclusion whether care delivered is safe
or not. The report further states that a direct influence on these indicators is exerted by
organisational, environmental and job factors. Individual as well as human characteristics
influence behaviour at work and therefore affect health and safety. Some of the noteworthy
human factors are leadership style of manager, communication, team leadership, situation
awareness, decision making ability, fatigue and stress. Kaufman and McCaughan (2013) also
consider good teamwork, effective leadership and a culture of learning and fairness as the
human factors related to patient care quality.
Cafazzo and St-Cyr (2012) support the idea as they state that role of human factors in
healthcare is definitely transformative. The authors reviewed the human factors that
contribute to the failure to deliver optimal quality health care. Active errors relate to those
made by the users systems, such as administration of wrong medicine. On the contrary, the
latent errors relate to those created by the organisation, such as incomplete training,
inadequate procedures, and poor labelling choices. Organisational factors and team factors
are significant concerns when it comes to quality of care provided. A culture of
misunderstanding and ‘blaming the other’ also contribute to adverse events. The research
paper also pointed out some other crucial human factors that play a key role in healthcare.
These are fatigue, cognition, consistency, workflow efficiency, visual and audible noise and
distractions and interruptions. The underpinning concept is that these human factors promote

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a rejection of the concept that humans are at fault while making errors in the delivery of care
using the socio-technical system.
Carayon et al., (2014) point out that a assortment of work system factors contributes
to medication errors in health care system. These are mainly human factors, including failure
to abide by the medication checking procedures, and issues with verbal or written
communication. Fryer (2013) adds to the knowledge on the factors that contribute to poor
quality care services. The authors state that healthcare service is complex and underpinning
human factors related to the work environment is paramount to care quality. In the
explanation put forward by Hookham (2016) on the human factors related to the death of
patients in hospitals, it has been mentioned that cognitive function is a key human factor
when it comes to making errors. Omission errors arise out of poor skill-based actions as these
are accountable for lapses and forgetfulness of completing a task. Lapses and slips in tasks
are a result of task overload, distractions and interruptions. Errors in rule-based actions
attribute to those that occur due to inability to cope up with the changed circumstances.
Humans need to retrieve stored schemas for matching with present circumstances. An error
would occur when a wrong schema is retrieved. Knowledge-based actions are common when
a person is unable to carry out the task due to limited knowledge.
The kinds of errors poined out by Hookham can be linked with the ideas of Henriksen
et al., (2008). The authors put the focus on interruptions in the care environment, poor
communication, diffusion of responsibility, and management neglect as the core human
factors contributing to poor quality care. These are the contributing factors towards the urgent
need of bringing reforms in the policies and procedures of the healthcare system. The
concepts are consistent with the research of Holden et al., (2013) who state that factors such
as poor communication and management neglect are a result of stress and fatigue. The two
forms of stress are chronic stress and acute stress. Job-related stress is the adverse reaction

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individual exhibit against demand placed on them or excessive work pressure. When such
stress is high, rates of accidents is more.
Patel and Kannampallil (2014) highlight the human factor of ability to utilise
technologies as a key element of patient care quality. As per the authors, adaptability to use
novice and modern technologies and implement them adequately depending on patient
condition is a key competency. Different patient safety tools have been developed that
ensures risks of patient harm are identified before-hand. A different concept has been put
forward by Sirriyeh et al., (2010) who state that errors due to human factors in a healthcare
setting give rise to feelings of guilt, shame, fear, anxiety and depression. In addition, self-
doubt and low morale and self-confidence are also crucial factors.
On the other hand, Xie and Carayon (2015) have to say that management of patient
safety undergoing treatment and diagnosis in a clinical setting needs the understanding of
organisational factors along with human factors for reducing iatrogenic injury and other
adverse effects. Safety culture is known to reflect professional’s attitudes and values in
relation to the management of risk and safety. The dimensions of safety culture include work
practices relating to safety, adherence to safety rules, management commitment to safety, risk
management, relative prioritisation of safety, and reporting of errors and incidents.
Critical analysis of the relationship between human factors and quality and safety in
health care
The relationship between human factors and quality and safety in healthcare is of
utmost importance in healthcare research. Cafazzo and St-Cyr (2012) highlight that working
healthcare professionals are not to assume that since they are facing challenges and
difficulties at a task, involving technology or not involving it, they would lead to an error.
They are also not to assume that the individuals who design the systems of healthcare

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technology are aware of the complexity of the environment in which professionals work.
Professionals deter from multitasking, leading to incompletion of tasks and missing of
deadlines at certain points. In addition, frequent interruption while performing tasks also
leads to errors.
The influence of the work system on care process is noteworthy. Carayon et al.,
(2014) had highlighted that nurses make medication errors that are preventable in the first
place. These include wrong patient; unordered or extra medication; an incorrect dose of
medication; incorrect drug; medication not administered; the incorrect route of administration
and improper timing of administration of medication. The authors opined that these issues
regarding medication safety relate to work system issues. The research undertaken by the
authors point out that lean thinking can be regarded as a change in the organisation leading to
negative and positive changes in the work system design. This, in turn, affects the healthcare
quality and the organisational outcomes. A care process is the array of tasks performed by the
professionals with the help of different technologies and tools in a particular environment.
The context of care is representative of transitions between more than one individuals and the
task done by them. In cases where coordination and collaboration between these individuals
are there, the care is not appropriate.
The human nature to not acknowledge own faults is elementary. Fryer (2013) argues
that humans have a predisposition to blame others for their failure and this takes a toll on the
quality of care delivered. In contrast to acknowledging the errors made, they run away from
the situation and deter from taking up the accountability of the mistakes made. The areas
where such instances are more prominent are a patient handover, medication safety, hand
washing and medical emergency situations. The research paper put forward by the authors
elaborates the impact of poor communication on patient safety. Communication in a
healthcare system provides knowledge of relationships and behavioural patterns of healthcare

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professionals. Failures in communication are a prime cause of preventable patient harm. A
large number of studies conducted have pointed out poor communication to be the root cause
of poor quality care delivery. Communication between different professionals playing
different roles is important when comprehensive care is to be provided. When the
communication between professionals is not effective, the issues that arise relate to patient
handover; information recorded in case notes, patient files and incident reports; speaking up
of junior staff and transfer of information between large organisations.
The effect of teamwork on patient care is noteworthy. Gurses et al., (2011) have given
insights into how the human factor of teamwork influences patient safety. Good teamwork
fosters the exchange of ideas that are crucial for addressing heath concerns of a patient in any
situations. In addition, it can promote the wellbeing and morale of the team members along
with team viability. Healthcare settings have fluid teams instead of fixed one. This means that
the contribution of each member is crucial if the set objectives are to be achieved. When the
manger acknowledges the team dynamics, the goals can be easily accomplished. Henriksen et
al., (2008) on the other hand puts the blame on the managers for contributing to poor quality
care. As per the researchers, it is the responsibility of the manager to demonstrate suitable
leadership and act as the vehicle for driving positive changes in the care setting. A manager,
and more precisely a leader needs to concentrate both on the contributions of each team
member and assimilation of the efforts put forward. When a leader does not assess the extent
to which the members can perform a task and demonstrate suitable competency skills, the
work they do is not aligned with the organisational objectives. Coaching and delegation are
what is needed when a manager gives instructions promoting healthcare. Holden et al., (2013)
stated that inadequate time-off, issues regarding workload and emotional aversion deters a
professional from putting in best efforts in care delivery.

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Kaufman and McCaughan (2013) explained that leadership is important in care
delivery as the absence of this skill puts a professional in a place wherein he is not able to
showcase critical thinking skills. Leadership is all about advocating for the patient and raising
a voice against any unethical or unjustified concerns in the setting. When a healthcare
professional does not have the required leadership skills, he is not able to report any
undesirable incident in the workplace, increasing the chances of reoccurrence of the incidents
that hamper patient safety.
Conclusion
Drawing insights from the above critical analysis of literature, it can be concluded that
humans are imperfect and they inherit the predisposition to make errors or mistakes. In a
healthcare setting, there exist fast-paced, dynamic and complex human factors. As a result,
error-provoking attributes can never be eliminated successfully. Though progress towards
improvement of patient safety has been witnessed in the past few decades, it is still slow and
not up-to-the-mark. A rationale for this undesirable slow speed is the insufficient
incorporation of human factors in these efforts. Patient safety issues are complex and are a
result of the multi-component system. Latent as well as prominent conditions arising due to
diverse human factors allow for inappropriate situations. Understanding the factors that lead
to the increased likelihood of error is the best strategy for preventing such errors. Different
measured for reducing chances of errors would be invented in future, as believed by different
scholars. Health care would certainly benefit at large from human factors evaluations as a
systematic process would be initiated to identify the issues, prioritise them and develop
practical solutions. Ongoing support and education would potentially decrease the burden of
human factors on care delivery process in the near future.

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References
Australian Institute of Health and Welfare 2016. (2016). Australia’s health 2016.Australia’s
health series no. 15. Cat. no. AUS 199. Canberra: AIHW. Retrieved from
https://www.aihw.gov.au/getmedia/3876a585-9a48-4553-8939-59711f1aa573/ah16-6-
14-safety-quality-australian-hospitals.pdf.aspx
Cafazzo, J.A., & St-Cyr, O. (2012). From discovery to design: The evolution of human
factors in health care. Healthcare Quarterly, 15(Special Issue),
24-29.doi:10.12927/hcq.2012.22845. Accessed via:
http://www.ncbi.nlm.nih.gov/pubmed/20543237
Carayon, P., Tosha, B. Wetterneck, A., Rivera-Rodriguez J., SchoofsHundt, A., Hoonakkera,
P., Holden, R., &Gurses, A. P. (2014). Human factors systems approach to healthcare
quality and patient safety. Applied Ergonomics, 45(1), 14–25,
doi:10.1016/j.apergo.2013.04.023. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3795965/
Fryer, L. A. (2013). Human factors in nursing: The time is now. Australian Journal of
Advanced Nursing (Online), 30(2), 56-65. Retrieved from
https://search.informit.com.au/documentSummary;dn=088490536520068;res=IELHEA
Gluyas, H., &Hookham, E. M. (2016). Human factors and the death of a child in hospital: A
case review. Nursing Standard 30(31), 46-51.
doi:http://dx.doi.org.ezproxy.uws.edu.au/10.7748/ns.30.31.46.s45
Gurses, A. P., Ozok, A. A., &Pronovost, P. J. (2012). Time to accelerate integration of
human factors and ergonomics in patient safety. BMJ Quality & Safety, 21(4), 347.

SURVEILLANCE AND DISASTER PLANNING
PMID: 22129929 DOI: 10.1136/bmjqs-2011-000421 Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/22129929
Henricksen, K., Dayton, E., Keyes, M.A., Carayon, P., & Hughes, R. (2008). Understanding
adverse events: A human factors framework. In R.G. Hughes, (Ed.). Patient safety and
quality: An evidence-based handbook for nurses, Chapter 5. Rockville (MD): Agency
for Healthcare Research and Quality (US). Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/21328766
Holden, R. J., Carayon, P., Gurses, A. P., Hoonakker, P., SchoofsHundt, A., Ozok, A. A., &
Rivera-Rodriguez, A. J. (2013). SEIPS 2.0: A human factors framework for studying
and improving the work of healthcare professionals and patients. Ergonomics, 56(11),
1669-1686, DOI: 10.1080/00140139.2013.838643 Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3835697/
Kaufman, G., &McCaughan, D. (2013). The effect of organisational culture on patient
safety.Nursing Standard, 27(43), 50-6. Retrieved from https://search-proquest-
com.ezproxy.uws.edu.au/docview/1399690410?accountid=36155
Patel, V. L., &Kannampallil, T. G. (2014). Human Factors and Health Information
Technology: Current Challenges and Future Directions. Yearbook of Medical
Informatics, 15(9), 58-66.doi: 10.15265/IY-2014-0005. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4287067/pdf/ymi-09-0058.pdf
Sirriyeh, R., Lawton, R., Gardner, P., &Armitage, G. (2010). Coping with medical error: A
systematic review of papers to assess the effects of involvement in medical errors on
healthcare professionals' psychological well-being.Quality and Safety in Health Care,

SURVEILLANCE AND DISASTER PLANNING
19(6), e43.doi:10.1136/qshc.2009.035253 Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/20513788
Xie, A., &Carayon, P. (2015). A systematic review of human factors and ergonomics (HFE)-
based healthcare system redesign for quality of care and patient safety. Ergonomics,
58(1), 33-49, doi: 10.1080/00140139.2014.959070. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4297241/pdf/nihms628158.pdf