Words By Charlotte Bronson
Human factors explore relationships between human beings and the systems with which they work in in an attempt to understand and minimise errors occurring. A key aspect of many adverse incidents in health care can be contributed to deficiencies in Human Factor principles. Therefore, there has been much more emphasis on healthcare related Human Factors in recent times. This short article will reflect on a case and discuss how Human Factors involved detrimentally affected a patient outcome.
A 50 year old male patient experienced severe back pain. The attending paramedic crew administered intranasal fentanyl appropriately however it failed to reduce his pain adequately. Following the patient handover at hospital, an attending nurse administered fentanyl with a very positive result. A subsequent investigation and audit revealed that certain medical and equipment checks had not been completed by either crew member prior to the start of the shift. Further investigation revealed that one of the crew had been syphoning Fentanyl therefore the correct dose had not been administered and that the appropriate drug checks had not been carried out.
Broadly, Human Factors can be divided into two areas (1). The first are factors within a system or organisation which can influence individuals and factors which directly influence individuals (1). Human Factors uses a people-centered approach and has a focus on building resilient systems through rigorous, evidence-based solutions. This allows safe and productive ways of working by enabling individuals to do the right thing (2). In paramedic practice, errors can be categorised as slips/trips/lapses, or mistakes (3). The possibility of error becomes less if the factors within a system are considered by their influence on other factors rather than individually (4). Rutherford (3) also suggests that human error should not be seen as the conclusion of an outcome but rather a starting point to review the system processes and that human errors are symptoms within the system. This author feels the key theme in this case study surrounds these processes, guidelines, and policies within the organisation and if these were addressed it could have positive ongoing outcomes for future Paramedics and patients. A change in the system at this point could potentially reduce errors going forward.
The first area identified within the organisation is system safety concerning not having a more experienced/supervisory crew member working with the paramedics who are new to the role. Research conducted by Reid et al (5) found that interviewees in the study identified clinical decision making as the main knowledge gap in newly graduated paramedics and that a period of supervised practice should be observed before authorisation can occur to be an independent practitioner. The importance of supervision, time and reflection is also highlighted by Gallagher et al (6).
The second aspect concerning safety is identified as the organisational culture. Safety culture is defined as the set of values placed on safety within an organisation and whether it allows for their employees to discuss errors openly and put risk reduction measures in place for the future (3). A “just” culture has an insistence on value based culture and shared accountability where all employees are held accountable for the quality of their actions (7). This would concern the decision made to complete initial checks later on in the day. Had the crew in question observed others doing this and seen it as ‘this is the way it’s done,’ would they have felt comfortable in that organisation to speak up if they didn’t agree? We will never know.
Regarding the syphoning of a Schedule 8 drug, though the individual has made the decision to steal the drug, the system itself must also be held accountable. This author would be concerned with the ‘why’ surrounding the theft of fentanyl. Individual Human Factors such as stress, fatigue, and distraction all contribute to having a negative impact on patient care and Paramedic wellness (1). The introduction of a self-assessment requirement such as IMSAFE prior to shift won’t fix all of the issues, however it will increase awareness of those elements. Hichisson & Corkery (8) identified unrealistic job demands, poor organisational support and insufficient training to perform roles led to occupational stress in health professionals including paramedics. In this case, the circumstances that led to the opiate addiction are also relevant. Factors such as the length of the standing addiction could mean that this was therefore missed in pre-employment screening. Or as it due to the stressful or traumatic nature of the job and role without adequate wellness check ins? These are questions that would need to be answered to determine the correct management strategy moving forward. This could be more rigorous employment psychometric testing or stronger mental wellness as well as addiction support.
Matheson (9) suggests that Crew Resource Management Training (CRM) should form a basis for paramedic practice as it addressed six key factors: fatigue, managing teams, decision making, recognizing adverse situations, cross checking/communication, and performance feedback. Initially used for aviation training it has applications across healthcare in that CRM addresses error causality by recognizing the human factors responsible (9).
Through this case study it was easy to lay blame on the individual paramedics involved in the incident however when looking at the overall situation, there were systematic failings in the lead up to this case which allowed errors to occur. The commencement of an audit of wellness and employment protocols as well the introduction of self-assessment tools for employees may reduce some of these issues occurring. This case highlights the need for supervision of new or recently trained employees as well as ongoing periodic supervision of all clinical operational staff. Incorporating additional CRM training into the induction and on-boarding process as well as non-technical skill development would result in a stronger and more resilient system for paramedics to work in and be part of.
1. Collen. A. Decision Making in Paramedic Practice. Burlington: Jones & Bartlett Learning; 2018.
2. Chartered Institute of Ergonomics & Human Factors. Human Factors and Healthcare. 2019.3.
3. Rutherford G. Human factors in paramedic practice. 2020.
4. Willis S, Dalrymple R. Fundamentals of paramedic practice. 2019.
5. Reid D, Street K, Beatty S, Vencatachellum S, Mills B. Preparedness of graduate paramedics for practice: a comparison of Australian and United Kingdom education pathways. Australasian Journal of Paramedicine. 2019;16.
6. Gallagher A, Vyvyan E, Juniper J, Snook V, Horsfield C, Collen A et al. Professionalism in paramedic practice: the views of paramedics and paramedic students. British Paramedic Journal. 2016;1(2):1.
7. Philip G. Boysen I. Just Culture: A Foundation for Balanced Accountability and Patient Safety [Internet]. PubMed Central (PMC). 2022 [cited 3 February 2022]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/
8. Hichisson A, Corkery J. Alcohol/substance use and occupational/post-traumatic stress in paramedics. Journal of Paramedic Practice. 2020;12(10):388-396.
9. Matheson R. Human factors in student paramedic practice. Journal of Paramedic Practice. 2019;11(1):15-20.