The General Medical Council has announced that all of their fitness to practise decision makers, case examiners and clinical experts are to receive human factors training. The GMC's fitness to practise directorate investigates complaints or concerns about doctors which could raise a risk to patients or damage public confidence in the profession.
Why is understanding human factors so important?
This change is one of a raft following the Bawa-Garba case. A computer failure – resulting in a delay receiving abnormal test results – was one of a myriad of factors in that case. There have been other high profile examples of systems failures this year. In May 2018 thousands of NHS patients discovered they were potentially at risk from missed invitations for breast screenings. A mistake in a computer algorithm meant 450,000 women were not invited to their final breast screening appointment. This was clearly a serious systems failure.
With increasing reliance on automation, computer systems and AI in healthcare, we may see more cases involving systems failures. However, it is not only electronic systems that fail; human errors are also common. Whilst these cannot be eliminated entirely, it is crucial that they are minimised.
Human factors is a social science that focuses on enhancing performance through understanding the behaviour of individuals and their interactions with each other and with their environment. The aim of human factors in healthcare is to enhance patient safety.
Human behaviour is affected by both internal and external factors. Internal factors include an individual's competence, emotional state and the ability to communicate with the rest of the team. External factors include suitable equipment, protocols and training. All these factors must be appreciated and understood, individually and collectively, as they can lead to systems failures.
The aim of these changes is to achieve consistency in GMC investigations and also ensure that a doctor's actions will not be considered in isolation. Instead, the GMC will consider the environment in which the doctor under investigation was operating. The aim is to ensure that, in addition to detecting any failures by the individual clinician, the effect of any systems failures will also be considered and individual failures put into that context. That could have been critical for Dr Bawa-Garba.
This is a positive development for both professionals and patients. Human factors analysis promotes safer systems for patient treatment. It should also militate against professionals being sanctioned when their actions should be considered alongside failures elsewhere in the system.
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