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Transcript of Mark Johnston driver diagrams
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Quality Education for a Healthier Scotland
Multidisciplinary
Introduction to Human Factors
Mark JohnstonTraining and Research Officer
(Patient Safety)NHS Education for Scotland
[email protected] 656 3258
Workspace
Culture
Organisation
TaskTeamwork
Individual Behaviours and AbilitiesAdapted from Catchpole
@markjohnston71
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Quality Education for a Healthier Scotland
MultidisciplinaryPre-requisite and/or reflective learning
E-learning course (for details see handout)
• Introduction to Patient Safety• Managing Human Error
Suggested reading and resources (for details see handout)
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Quality Education for a Healthier Scotland
Multidisciplinary
Learning Outcomes
At the end of the session you will be able to
• Define Human Factors • Describe how factors impacting on an individual may increase
the likelihood of error• Explain the systemic factors that increase the likelihood of error
During the session you will
• Participate in discussion with delegates• Formulate an action plan for discussion with colleagues back in
your work setting
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Quality Education for a Healthier Scotland
MultidisciplinaryHow safe is healthcare?
What percentage of patients entering acute care will suffer an adverse event?
NES 2013
The picture in primary care…
• 11% of prescriptions may contain a mistake• 5% of hospital admissions are caused by
medication issuesBowie, P. 2010
10%
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Quality Education for a Healthier Scotland
Multidisciplinary
Why do all those avoidableharms happen?
“Just a routine operation”
https://vimeo.com/970665
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Quality Education for a Healthier Scotland
Multidisciplinary
Bad people?
Error occurs due to Systemic and Systemic induced Individual failure
Negligence is not the same as error, both may result in harm
Why do all those avoidableharms happen?
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Quality Education for a Healthier Scotland
Multidisciplinary
75 HF facilitators workshop Sept 11
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Quality Education for a Healthier Scotland
MultidisciplinaryAn example
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Quality Education for a Healthier Scotland
Multidisciplinary
You’re amazing!
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Quality Education for a Healthier Scotland
MultidisciplinaryWhy do we err?
• Sometimes we do the wrong thing, consciously and sub-consciously
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Quality Education for a Healthier Scotland
Multidisciplinary
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Quality Education for a Healthier Scotland
Multidisciplinary
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Quality Education for a Healthier Scotland
Multidisciplinary
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Quality Education for a Healthier Scotland
Multidisciplinary
Even experts err
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Quality Education for a Healthier Scotland
Multidisciplinary
The first lesson in reducing avoidable harm is the realisation that we will and do make mistakes
‘It’s the downside of having a brain!’
Reason
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Quality Education for a Healthier Scotland
MultidisciplinaryWhy do we err?
• Sometimes we do the wrong thing, consciously and sub-consciously
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Quality Education for a Healthier Scotland
Multidisciplinary
<1% 5% 50% 80% 100% percent of drivers
PERFORMANCE
Indi
vidu
al A
uton
omy
The posted speed limit is 60 mph- the ‘legal’ space
Driving 64 mph-the illegal-
normal space
Driving75 mph – the ‘illegal-illegal’ space (for almost all of us!)
VE
RY
UN
SA
FE
SPA
CE
IndividualPressures
PerceivedVulnerability
Belief inSystems-guidelines
Accident
Driving 100 mphillegal for all Borderline Tolerated
Conditions of Use
Adapted from Rene Amalberti
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Quality Education for a Healthier Scotland
MultidisciplinaryDiscussion point
When are you more likely to make mistakes?
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Quality Education for a Healthier Scotland
Multidisciplinary
Factors impacting on an individual that contribute to error
• Stress• Fatigue• Illness• Hunger/Thirst• Hazardous attitudes• Language and cultural factors
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems for the individual• Begin to complete your action plan
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Quality Education for a Healthier Scotland
MultidisciplinaryBreak
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Quality Education for a Healthier Scotland
Multidisciplinary
Human FactorsA common language
“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture and organisation on human behaviour and abilities and application of that knowledge in clinical settings” (Catchpole 2010)
“Making it easy to do the right thing” (Bromiley 2011)
Organisational/ Management-Safety Culture
-Managers’ Leadership-Organisation communication
Work/Environment-Work environment
and hazards(ergonomics)
Workgroup/Team-Teamwork
structures & processes-Team Leadership
Individual Worker-Cognitive skills
• Situation awareness• Decision making- Personal resources
• Management of stress• Management of fatigue
(Flin, Patey 2012)
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Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Individual Worker-Cognitive skills
• Situation awareness• Decision making
- Personal resources• Management of stress• Management of fatigue
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Quality Education for a Healthier Scotland
Multidisciplinary
Cognitive skills and Situation Awareness
• Multi-tasking• Task focus
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Quality Education for a Healthier Scotland
Multidisciplinary
Multi-tasking is hard - Our lazy brains would rather default to system 1.
2 x 2=
17 x 379 =
4…System 1
6443…System 2
Now try and multi-task - do an equally difficult math problem and walk at the same time!
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Quality Education for a Healthier Scotland
Multidisciplinary
Card suit change game
Groups of three
• Person A (dealer) deals cards, turning them face up in rapid succession
• Person B (subject) estimates the passing of time with no aid and counts the number of card suit changes.
• Person C (observer) times the activity using an aid and focuses on recording the suit changes
When the facilitator signals the end, B & C separately record the time and number of suit changes and then compare results.
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Quality Education for a Healthier Scotland
Multidisciplinary
The amazing colour changing card trick
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Quality Education for a Healthier Scotland
MultidisciplinaryExamples of individual solutions
Can you think of solutions to the problems individuals face?
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems• Continue to complete your action plan
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Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Workgroup/Team-Teamwork
-Team Leadership
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Quality Education for a Healthier Scotland
Multidisciplinary
Characteristics of a High Performance Team
1. Clear Objectives2. Encouragement of Participation3. Emphasis on Quality4. Support for Innovation5. Communication
Borrill et al.
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Quality Education for a Healthier Scotland
MultidisciplinaryTeam communication
‘The task of communication between health providers can be complicated…
an effective team is one where the team members, including the patient, communicate with one another to optimise patient care.’
WHO Multi-Professional Curriculum Guide Content Summary
‘Being an effective team player’
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Quality Education for a Healthier Scotland
Multidisciplinary
So... Teams:
• Work together • Deliver services• Mutually accountable
• Another slice of cheese
• Share goals• Interdependent in their
accomplishment• Integrating is the
responsibility of all.
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Quality Education for a Healthier Scotland
Multidisciplinary
Communication – a wicked problem?
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Quality Education for a Healthier Scotland
Multidisciplinary
Different mental models?
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Quality Education for a Healthier Scotland
MultidisciplinaryTeachback
Do you understand?
Do you have any questions?
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Quality Education for a Healthier Scotland
Multidisciplinary
Initiate teach-back in a non-shaming way
• “I want to be sure I explained everything clearly. Can you explain it back to me so I can be sure I did?”
• “What will you tell your husband about the changes we made to your medicines today?”
• “We’ve gone over a lot of information. In your own words, please review with me what we talked about.”
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Quality Education for a Healthier Scotland
MultidisciplinaryTeachback
http://vimeo.com/50438604
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Quality Education for a Healthier Scotland
Multidisciplinary
Decode technical language
• wean PS reduce help from breathing machine
• haemofilter kidney machine
• Inotropes blood pressure medicine
• central line big drip in the neck
• ET tube breathing tube
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Quality Education for a Healthier Scotland
Multidisciplinary
Be creative about how and when you use teach-back
• Focus on nodal points to optimise effectiveness– New diagnosis– Change in treatment– High risk medications– Vulnerable segments of population
• Make use of all staff groups– Nurses and AHPs– Reception staff
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Quality Education for a Healthier Scotland
MultidisciplinaryHudson Bay
An example of great communication that saved lives.
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Quality Education for a Healthier Scotland
MultidisciplinaryTake a moment to reflect and discuss
What stood out for you?
• Crew had never flown together before• Structured communication/calm• Errors still crept in• Checklists used• Others??
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Quality Education for a Healthier Scotland
MultidisciplinarySBAR
• Situation• Background• Assessment• Recommendation.
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Quality Education for a Healthier Scotland
Multidisciplinary
Yorkhill
http://www.nhsscotlandevent.com/resources/resources2013/keynote_sessions/yorkhill_safety_huddle
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems• Continue to complete your action plan
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Quality Education for a Healthier Scotland
MultidisciplinaryLunch
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Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
Organisational/ Management
-Safety Culture-Managers’ Leadership
-Organisation communication
(Flin, Patey 2012)
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Quality Education for a Healthier Scotland
MultidisciplinaryThe Scottish Approach to improving healthcare
• Safe• No avoidable injury or
harm from the healthcare they receive
• Effective
• Person Centred
• Safe• Effective• Patient
Centred• Timely• Efficient• Equal
The Institute of Medicine – 2001
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Quality Education for a Healthier Scotland
Multidisciplinary
‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’
culture
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Quality Education for a Healthier Scotland
Multidisciplinary
Silo working?
Doctors
Managers
Nurses
What is your culture?
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Quality Education for a Healthier Scotland
Multidisciplinary
Hierarchies?
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Quality Education for a Healthier Scotland
Multidisciplinary
Reporting incidents - Do we pay attention to the Swiss cheese or do we blame?
Our learned behaviour is to blame an individual
Society
System
End point (Colleagues)?
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Quality Education for a Healthier Scotland
Multidisciplinary
Lessons for Leadership inchanging culture
Culture change and continual improvement come from what leaders do, through their commitment, encouragement, compassion and modelling of appropriate behaviours.
Berwick Report 2013
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Quality Education for a Healthier Scotland
Multidisciplinary
The additive effect of Transformational Leadership
Expected Outcomes
Contingent Reward
+
Management-by-Exception
Performance beyond expectations
Transformational Leadership
Idealized Inspirational Intellectual Individualized
Influence Motivation Stimulation Consideration
Adapted from Northouse
Transactional Leadership
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Quality Education for a Healthier Scotland
MultidisciplinaryLeadership
Lots of models
• Crises – Command and directive style• Tame – Managerial, standard operating procedures• Wicked – Ask questions, seek expertise from within and without
the team
Adapted from Grint 2010
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Quality Education for a Healthier Scotland
Multidisciplinary
Problem Response Method
Tame Management
Process
Critical Command Answer
Wicked Leadership Question
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems• Continue to complete your action plan
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Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Work/Environment-Work environment
and hazards(ergonomics)
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Quality Education for a Healthier Scotland
Multidisciplinary
‘We cannot change the condition of those who do the work, but we can change the conditions within which they work’
Reason J. BMJ. 2000 March 18; 320(7237): 768–770.
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Quality Education for a Healthier Scotland
MultidisciplinaryEveryone, everywhere, every time
Good human factors design in health care accommodates everyone
Not just the calm, rested experienced healthcare worker
But also the inexperienced health-care worker who
might be stressed, fatigued and rushing.
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Quality Education for a Healthier Scotland
Multidisciplinary
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Quality Education for a Healthier Scotland
MultidisciplinaryActivity
Discuss in groups a problem you encounter with the work environment.
Can you think of a design solution to either the process or equipment?
Perhaps you can add it to your action plan?
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Quality Education for a Healthier Scotland
Multidisciplinary
Rsaeecrh by Crmabgdie Uiisvnerty has rlveaed that so lnog as the frist and lsat lteetrs of a wrod are in the ccrroet pclae tehn the bairn wlil urdtsnaned and itpnrertae. Tihs has ilpmcotnias for stfeay
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Quality Education for a Healthier Scotland
Multidisciplinary
GabAPentin
GemFIbrozil
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems• Continue to complete your action plan
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Quality Education for a Healthier Scotland
Multidisciplinary
Where can we start?
“Making it easy to do the right thing” (Bromiley 2011)
(Flin, Patey 2012)
Workgroup/Team
Structures & processes
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Quality Education for a Healthier Scotland
MultidisciplinaryDiscussion point
Under what circumstances are errors more likely to occur?
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Quality Education for a Healthier Scotland
MultidisciplinarySituations when error is more likely to occur
Unfamiliarity with the task
Inexperience
Shortage of time
Inadequate checking
Poor procedures
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Quality Education for a Healthier Scotland
Multidisciplinary
How do you improve the quality of care of this system?
http://www.youtube.com/watch?v=UmzDLSAEhcc
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Quality Education for a Healthier Scotland
MultidisciplinaryWhy does error happen?
The system may be set up to ensure we fail
‘every system is perfectly designed to achieve the results it gets’
Peter Senge
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Quality Education for a Healthier Scotland
MultidisciplinaryExamples in healthcare…
• Prescribing and dispensing
• Hand-over/hand-off information
• Movement of patients
• Order of tests
• Preparation of medication
• If all of the processes associated with these tasks make sense and become easier for the ‘human’ to comply with, then patient safety will improve.
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Quality Education for a Healthier Scotland
Multidisciplinary
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Quality Education for a Healthier Scotland
Multidisciplinary
Systems thinking - The patients perspective?
• Value for the patient
• Hand-offs
• Accountability for the end-to-end experience
• Job roles
Organisational/departmental boundaries
A B C D E
Diagnostic process
Emergency care process
Treatment process
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Quality Education for a Healthier Scotland
Multidisciplinary
“What matters to you?” not “What's’ the matter”
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Quality Education for a Healthier Scotland
Multidisciplinary
Improved reliability of process = Improved Outcomes
0
1
2
3
4
5
6
7
8
Oct
-06
Feb
-07
Jun-
07
Oct
-07
Feb
-08
Jun-
08
Oct
-08
Feb
-09
Jun-
09
Oct
-09
Feb
-10
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-10
Feb
-11
Jun-
11
Oct
-11
Feb
-12
VA
P I
nci
den
ce (
ou
tco
me
mea
sure
)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bu
nd
le R
elia
bil
ity
(pro
cess
mea
sure
)
151 147 262 days Days
609+ Days
Ventilator Associated Pneumonia – Forth Valley ICU
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Quality Education for a Healthier Scotland
Multidisciplinary
Aggregation of marginal gains
• Small improvements in a number of different aspects of what we do can have a huge impact to the overall performance of the team
Sir Dave Brailsford - Performance director of British Cycling and the
general manager of Team Sky.
Improve 100 things by 1%
Don’t try to fix the whole system!
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems• Continue to complete your action plan
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Quality Education for a Healthier Scotland
MultidisciplinaryBreak
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Quality Education for a Healthier Scotland
MultidisciplinaryReview of actual incidents
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Quality Education for a Healthier Scotland
Multidisciplinary
805 HF facilitators workshop Sept 11
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Quality Education for a Healthier Scotland
Multidisciplinary
http://t.co/aSIEwiGD8n
http://t.co/aSIEwiGD8n
http://t.co/aSIEwiGD8nhttp://t.co/aSIEwiGD8n
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Quality Education for a Healthier Scotland
MultidisciplinaryAction plan
• Reflect on what you have heard so far• Contextualise for your workplace setting• Consider systemic problems interacting to produce
problems• Complete your action plan
![Page 83: Mark Johnston driver diagrams](https://reader033.fdocuments.net/reader033/viewer/2022052505/554b0dd2b4c90569098b47e6/html5/thumbnails/83.jpg)
Quality Education for a Healthier Scotland
Multidisciplinary
Introduction to Human Factors
Mark JohnstonTraining and Research Officer
(Patient Safety)NHS Education for Scotland
[email protected] 656 3258
Workspace
Culture
Organisation
Task
Teamwork
Individual Behaviours and AbilitiesAdapted from Catchpole
@markjohnston71