Patient safety – Human factors

The science of human factors examines how humans interact with the world around them and how system aspects, including processes, environment, equipment, and the broader organisational and cultural context, can influence human performance. It recognises that problems arise where there is an over-expectation of human performance, which is prone to human error, and a requirement for humans to work around a poorly designed system. Human factors such as fatigue, stress, and poor communication can all increase the risk of human error occurring.

A lack of understanding of human factors can lead to human error being identified as the main contributor to a patient safety event. An incident investigation in this context may lead to a weak response including the creation of new procedures, additional training, disciplinary action or an encouragement for increased personal vigilance – approaches which focus almost exclusively at identifying and addressing an individual’s failure. This approach is not likely to be successful in preventing the same or similar incidents from reoccurring due to the focus on the individual and the potential for the human factors that lead to the event to occur in any staff member.

Patient safety can be improved by identifying and understanding the human factors at play in the healthcare setting and putting in place interventions that support staff to reduce the impact of these human factors. This approach adopts the view that human error is a symptom of broader issues within a poorly designed system. It understands that humans are fallible and errors are to be expected, even within the best performing organisation. This view assesses the individual’s actions within a wider context of circumstances which occurred at the time of the event and endeavours to uncover more system based contributing factors.

Watch these videos on error tolerance (external site) and human factors (external site) presented by Dr Matthew Thomas.

Human factors training (external site) is available in Western Australia through the Royal Perth Bentley Group of the East Metropolitan Health Service.

Human factor-based leadership

An understanding of human factors is critical in leadership roles that are involved in the design of our healthcare systems. This understanding is equally important when a patient safety event does occur and the investigation and analysis that follows. The NSW Clinical Excellence Commission’s 'Leading in a Crisis' (external site) series outlines five critical elements of high-performance leadership:

  • trust
  • courage
  • commitment
  • ownership
  • mission focus.

More information

Patient Safety Surveillance Unit

Last reviewed: 08-04-2022
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Patient Safety Surveillance Unit