Hello I am Peter-Marc Fortune and I am the consultant Paediatric Consultant Intensivist
based at Royal Manchester Children’s Hospital and also chair of MIST, the Making It Safe
Together, the paediatric safety collaborative.
I am going to talk to you today about Human Factors and how they come to play at a time
of a child’s deteriorating or unwell under your care.
First and most importantly I want to make the point that recognising deterioration in
a child is simple.
We look at them and we put together what we actually found and recognise as what’s going
on and then we escalate as appropriate and that might by intervening and delivering some
care or it might be calling for help depending on the situation.
So what can go wrong?
Well what can go wrong is that we are human beings.
Human beings are fallible, human beings make mistakes.
There is no way of getting away from that we all do it.
With the best will in the world it is impossible to stop that all together.
What we can do is understand some of the mechanisms that go behind those occasions we make mistakes
and by recognising where things are going wrong, we can stop things in our tracks and
hopefully prevent a mistake turning into harm for a child.
So the context of this is really really important, when we come to work every day, we all come
in to do the absolute best that we can.
We come in to look after every child and get them back home at least as well as they came
and hopefully way better than they came in.
That’s our goal.
So what goes wrong?
Well human factors recognises the fact that often when things go wrong it’s because
at the time it seemed right and so you proceeded down a particular path because that seemed
like the best thing to do and this pivots on something called situation awareness.
Situation awareness is a concept where we enter a scenario so in particular a room with
an unwell child in it and we are coming to care for them.
We are assembling a whole stack of information like pieces of a jigsaw puzzle.
And they pull them all together and fit them into a map in their own heads of what’s
actually going on and that allows them to understand where they are at the current time
but also project forwards and make an appropriate plans to go into the future and give the right
care to the child.
Obviously right at the beginning there are often gaps or even later on there could be
gaps as well and it’s important that we spot those gaps and we look to plug them along
the way but it’s important that we assimilate any other new pieces of information that we
may not be expecting if you like.
I’ll come back to this particular scenario as I go on in the talk.
The other thing that’s important is even when we think we have the whole situation
sometimes there can be some blurry bits or things we are not sure about.
We have to look very closely and I think of this example in the picture of this young
lady.
So if you were asked to describe this picture, the first words might be its actually quite
blurry, so we can sort that out and bring it into focus but actually there is still
something missing.
So if you were describing this young lady it would be nice to actually say that she
has got pink glasses on.
So there was a little bit more information that wasn’t entirely obvious that it was
missing and again that could be one of things that can really throw you in fully assembling
good situation awareness.
The last bit is to listen of all the information that is coming in from all the people that
are feeding it in so Maya who very kindly lent me her jigsaw to put together the slides
in this talk has got the missing piece for us and the important thing about picking her
out is that it could be anybody in the room or anyone involved in the care of the child
that holds that missing piece.
No matter how junior, no matter non-medical or general their background.
You must listen to everything and assemble those pieces into the overall picture
What I want to do is look at situational awareness, particularly in the context of a child that
is deteriorating and I want to focus on Early Warning Scores.
Something called fixation and confirmation bias, I want to think about our interaction
with colleagues and also talk about those times when things don’t quite make sense
and potentially even were a little bit confused.
So with the early warning score this would be very familiar.
A child presents in the emergency department and the nurse does the initial assessment
of the child, does the observation but may note along the way that the child has got
an unusual rash.
This one looking a lot like a meningeal coccal rash, quite naturally the nurse would be concerned
about that, she actually then goes to do the scoring and work out the Early Warning Score
and can see that it is very low and therefore things are ok, well clearly they are not ok
so what has gone wrong?
Well what has gone wrong is that the tools have been used in the wrong way.
An Early Warning Score is exactly that, it’s about warning.
It is not about reassurance and mustn’t be used in that fashion, it must only be used
as an Early Warning Score.
So tools, clinical tools, must be used in the right way that is very very important.
Fixation and confirmation bias is another feature that we still see.
Not uncommonly we will be a chain of people delivering care to a child and it’s quite
possible that a diagnosis handed over to us at the point of we received the child so a
child coming in to hospital from the emergency department for example a baby might be presented
and shared with us as having a chest infection.
As more information comes available from lab results and from the x-ray it may be that
what we may have is information that actually challenges that.
So a white cell count that isn’t raised, no changes on the x-ray so the information
doesn’t really fit with where we actually started.
We are very good at making it fit that diagnosis and the most important thing is when you have
got something that clashes is to start again.
So re-examine it, think again, and start at square one.
Be very ready to throw out your presumptions and that diagnosis that was handed over to
you, even if it was someone senior who you had great respect for because they didn’t
have the information that you have now got.
That’s important so think again.
The other situation which is very similar to this is in a pressured and busy environment
sometimes information can be coming at you at just a rate that is very difficult to absorb
or actually you feel quite alarmed by at the time and it’s kind of easy to look at one
side and try not to look at it because actually it’s going to take too much of your time
which you haven’t got or its scary.
Please don’t do that, it’s really really important that every new piece of information
is looked at carefully don’t disregard anything or ignore it because it’s necessary to build
that correct picture to do the right thing for the child.
Much of what we do when looking after a children is working with colleagues on that.
We are always part of the team along the way and in conversation with colleagues.
I know that I not uncommonly find myself wondering quite why they have come to talk to me about
a child on a particular occasion.
And that should be ringing a little bit of an alarm bell with you because they will have
had a reason behind it and I have just listed a set of questions here which I recommend
you run quickly through your mind at any communication point.
So why have they rung me?
If it’s not clear, ask them!
So if you have talked for a while and you’re not sure what their worries about say what
is it that you actually need from me, why are you worried?
You need to understand that to make sure that you have got the right information, going
backwards and forwards between you.
If they are describing a child to you, check their situational awareness, have they got
all the key information or is there something that’s missing, something you might be able
to augment through experience and ask them to look for.
And if you give advice make sure they understand what you have actually said to them and taken
that on board and understand the plan and I could have talked for the whole ten minutes
about communication but I have just want to nail a couple points there and discuss these
conversations and that is that it’s a two way process; its listening as well as talking
but more importantly it’s about closing loops and in the process of communicating
we actually summarise back to one another the things that have been said, we confirm
the content of it and put it into different words.
And actually using a structure like SBAR or SBAR(D) is something that can add an awful
lot to that because it’s a familiar structure that everybody can actually latch into.
Finally on the main issues of human factors are confusion.
So sometimes as you look at that picture, looking at the assembled jigsaw puzzle, you
realise it doesn’t make sense to you that in human factors speak is a massive red flag.
That’s an occasion where something is screaming at you that situational awareness is at fault
and you don’t quite have the right picture.
So always, always discuss with somebody.
Always go and try and find the missing piece, always escalate if that’s what’s needed
to somebody with greater experience.
On top of all these factors that we have talked about other pressures come to bear on us on
a clinical environment.
I think the most obvious one is anxious or demanding people, people who are asking questions
all the time.
They are asking them with the exactly right motivation, they’re advocating for the child,
they’re trying to make sure that the child is safe but it can turn into this ‘cry wolf’
situation particularly when there is multiple false alarms where you can tone down your
own response if you are not careful and this can be brought into very sharp focus by anxious
parents who are asking a lot of questions and are pushing very hard because of their
fears for their child.
These are things that one needs to be very conscious of and one supresses them and make
sure that every time that a new piece of information comes forward its treated as just fresh, its
treated with a fresh look and you are not coloured by what happened before because it
might be the occasion where the child is deteriorating and actually needs an action from you to sort
things out.
And finally pulling it all together, I want to talk very briefly about leadership.
Many of the children we look after are quite complicated and under the care of multiple
allied health professionals and doctors and nurses and physics, all sorts of people.
The problem there is someone doesn’t have the overall picture of what’s going on.
They are all focused on their own little corners of what’s going on.
The right big toe specialist on his computer focusing in on that.
What we need is that person with the overview, that person that looks at everything that
is going on.
They might just see the pattern of why the child is getting into difficulty.
So that’s an important component of any team, that you have got a clear leader in
there.
So I would just like to summarise.
Looking after a deteriorating child is easy.
You look at them, we recognise what’s going on and you respond but there are some really
important caveats in there.
If you are worried talk to someone or escalate.
If a conversation or handover isn’t entirely clear to you, ask again, get it clarified,
that is really important.
And if it’s you that’s actually being asked for advice then it takes that little
bit more as well.
You need to listen, you need to understand and you need to support that individual.
If you would like any further information about any of this you are very welcome to
contact me on the email address shown on this slide.
There’s also information on both the MIST and ALG websites about human factors and both
of these organisations tweet regular safety information.
Thank you very much.