We Knew This Years Ago. So Why Are We Still Getting It Wrong?
I first met Martin Bromiley in 2010.
That was more than a decade before I found myself asking a rather uncomfortable question:
Why, in 2021, was Human Factors training still little more than lip service in some hospitals?
Human Factors was not some fashionable new management concept. It was not an experimental theory waiting for evidence. And it certainly wasn’t something invented by an education department to fill an afternoon on the mandatory-training calendar.
By then healthcare had spent years being shown, repeatedly and sometimes tragically, that technically competent people working in badly designed systems can still make catastrophic mistakes.
Martin Bromiley understood this in perhaps the most devastating way imaginable.
His wife, Elaine, died in 2005 following complications during what should have been routine surgery. The subsequent investigation did not uncover a theatre full of incompetent clinicians. Quite the opposite.
They were trained.
They were experienced.
They had the necessary equipment.
But the team lost situational awareness. Communication deteriorated. Leadership became confused. Attempts by members of the team to speak up failed to alter the developing situation.
The Clinical Human Factors Group grew from the recognition that the problem was not simply what individual clinicians knew.
It was how humans behaved within a complex system when that system came under pressure.
Martin founded the Clinical Human Factors Group in 2007.
I met him in 2010.
And even then the principles seemed obvious.
Healthcare could learn enormously from aviation, nuclear power, engineering, the military and every other high-risk industry that had realised a simple truth:
You cannot eliminate human fallibility.
What you can do is design systems that recognise it.
Human Factors therefore concerns considerably more than communication skills.
It includes situational awareness, cognitive overload, fatigue, hierarchy, authority gradients, fixation, distraction, task design, ergonomics, decision-making, leadership, teamwork, interruptions, environmental pressures and the ability of somebody relatively junior to say:
“Something is wrong.”
And, crucially, to be listened to.
The aviation analogy is sometimes overused, but the central lesson remains compelling.
Airlines do not assume that experienced pilots will never make mistakes.
They assume that they will.
The system is therefore designed around detecting, trapping and mitigating those mistakes before several small failures align to produce catastrophe.
Healthcare has historically been rather less comfortable with that idea.
We have frequently built systems around the assumption that competent professionals should simply cope.
Work harder.
Pay more attention.
Don’t make mistakes.
And when something goes wrong, find out who failed to follow the policy.
That is almost the opposite of Human Factors thinking.
We Had Already Been Warned
By 2021, healthcare could hardly claim ignorance.
The WHO Surgical Safety Checklist had been launched in 2008.
It became mandatory within the NHS in England in 2009.
Its importance was never simply that somebody remembered to tick a box.
Its purpose included getting surgeons, anaesthetic practitioners, nurses and the wider operating team to communicate at critical moments.
The evidence became compelling enough that studies associated with the introduction of the checklist reported substantial reductions in surgical complications and mortality.
But even the WHO recognised something profoundly important:
A checklist without an appropriate culture is just a piece of paper.
Successful implementation required leadership.
Staff engagement.
Multidisciplinary education.
Clinical champions.
Feedback.
Communication.
In other words, many of the same principles that underpin Human Factors itself.
Yet years later it was still possible to walk into hospitals where the WHO checklist was technically being performed while almost everything it was designed to achieve had been forgotten.
I have watched checklists conducted while somebody completed paperwork.
I have seen people continue preparing equipment while another member of the team spoke.
I have seen introductions reduced to everybody mumbling their names into the middle distance.
And occasionally the entire exercise appeared to have become theatre in the theatrical rather than clinical sense:
We have performed the checklist, therefore we are safe.
No.
You have performed a ritual.
There is a difference.
A Private Sector Hospital
This became particularly relevant to me in 2021.
It had been identified that structured Human Factors training was effectively absent within a private sector hospital.
For an organisation providing complex surgical healthcare, I thought this represented an obvious educational opportunity.
So I developed one.
Not a twenty-minute PowerPoint presentation.
Not an e-learning module requiring employees to click “next” until a certificate appeared.
A proper one-day Human Factors event.
The intention was to bring together people who actually understood the subject.
Lectures were arranged or proposed involving representatives associated with Martin Bromiley’s Human Factors work, an Oxford professor who had played an important role in the response to the WHO Safe Surgery Saves Lives initiative, the President of the College of Operating Department Practitioners, and other respected leaders within Human Factors and perioperative healthcare.
The purpose was simple.
If we were going to teach Human Factors, let’s have it taught by people who had actually helped shape Human Factors in British healthcare.
I expected some discussion around logistics.
Cost.
Staff release.
Venue capacity.
Clinical cover.
Those would have been perfectly reasonable organisational questions.
What I did not expect was for the credibility of the proposed speakers themselves to be questioned.
Yet that was essentially what happened.
And it produced one of those moments when you wonder whether everybody is having the same conversation.
We were proposing to bring nationally recognised expertise into the organisation to discuss one of the most important areas of modern patient safety.
And rather than asking:
“How can we make this happen?”
the response included questioning whether the people being invited were sufficiently credible.
There is something almost magnificently ironic about an organisation demonstrating a Human Factors problem while considering whether it should support Human Factors training.
The Problem Is Not Usually Knowledge
This is where I think healthcare sometimes fundamentally misunderstands Human Factors.
The problem is rarely that nobody has written a policy.
Healthcare is drowning in policies.
There are policies about communication.
Policies about escalation.
Policies about incident reporting.
Policies about surgical safety.
Policies about deteriorating patients.
Policies about staffing.
Policies explaining the other policies.
The question is what happens at 03:17 in the morning when somebody is exhausted, two emergencies arrive simultaneously, an experienced consultant has made a decision, a relatively junior practitioner thinks something is wrong, three alarms are sounding and everyone is experiencing cognitive overload.
Does the system still work then?
That is Human Factors.
What happens when the senior surgeon says:
“Carry on.”
and the junior member of staff thinks:
“We shouldn’t.”
That is Human Factors.
What happens when everybody in a room individually notices something unusual but assumes somebody else has dealt with it?
That is Human Factors.
What happens when someone becomes fixated on the diagnosis they originally made and unconsciously filters subsequent information to support it?
That is Human Factors.
What happens when a practitioner has worked twelve hours, missed lunch, answered forty interruptions and then draws up the wrong drug?
That is Human Factors.
The lazy explanation is:
They should have been more careful.
The useful question is:
Why was the system relying upon somebody being perfect?
Training Is Not Enough Either
There is another uncomfortable point.
Even excellent Human Factors training achieves very little if the organisation sending people to it behaves in precisely the opposite way.
You cannot teach psychological safety at 10am and punish people for challenging authority at 2pm.
You cannot lecture staff about fatigue while routinely designing rotas that produce exhaustion.
You cannot teach communication while creating a hierarchy in which junior practitioners are frightened to speak.
You cannot teach incident reporting and then create an investigation culture principally concerned with identifying who is responsible.
And you certainly cannot describe Human Factors as an organisational priority while treating meaningful Human Factors education as optional.
Human Factors has to exist from Board to Ward.
It has to influence procurement, staffing, theatre design, rostering, equipment standardisation, clinical pathways, education, leadership and incident investigation.
Otherwise it becomes another poster on the wall.
The Checklist Is Not the Safety System
One of the greatest risks in healthcare is confusing the visible tool with the philosophy behind it.
The WHO Surgical Safety Checklist is not what makes surgery safe.
A functioning team makes surgery safer.
The checklist creates a structured opportunity for that team to communicate.
Similarly, an incident-reporting system does not create a safety culture.
A culture in which people feel able to report incidents honestly creates one.
A Human Factors lecture does not create Human Factors.
An organisation that understands how people actually behave creates systems based upon those realities.
That distinction matters enormously.
Because healthcare has become very good at demonstrating compliance.
It is considerably harder to demonstrate culture.
So Why, in 2021, Were We Still Having This Conversation?
That remains the question that bothers me.
Martin Bromiley had been campaigning publicly on Human Factors since the 2000s.
The Clinical Human Factors Group had existed since 2007.
The WHO Surgical Safety Checklist had been launched in 2008.
The NHS had mandated it in 2009.
Research, investigations and countless serious incidents had repeatedly demonstrated the consequences of communication failures, hierarchy, fixation, poor situational awareness and dysfunctional team dynamics.
Yet more than a decade later I was attempting to organise meaningful Human Factors education within a major private-sector healthcare setting and finding myself having to justify the credibility of some of Britain’s most experienced people in the field.
Perhaps that tells us something important.
Healthcare’s biggest Human Factors problem may never have been a lack of knowledge.
We knew.
We had known for years.
The harder problem was convincing organisations to change the way they thought.
And there is an enormous difference between having a Human Factors policy and having a Human Factors culture.
One can be written in an afternoon.
The other may take years.
But when the next avoidable serious incident occurs — and an investigation concludes that there were failures of communication, situational awareness, escalation, leadership or teamwork — we should perhaps stop describing those findings as lessons to be learned.
Because many of them aren’t new lessons at all.
They are lessons healthcare has already been taught.
The uncomfortable question is why we keep having to learn them again.
#HumanFactors #ClinicalHumanFactors #PatientSafety #CHFG #SurgicalSafety #JustCulture #SpeakingUp
