Human factors: keeping surgeons and patients safe on ward rounds

“Patients, families and carers can be physically and psychologically traumatised and often experience additional and prolonged harms due to lack of apology, openness and transparency.” 

These words from an important 2023 paper, co-authored by Professor Paul Bowie, titled Patient safety learning for healthcare improvement: considering the “system context” in medico-legal cases? outline Bowie’s motivation to improve patient safety, particularly in his work around human factors. 

Bowie holds a number of roles related to patient safety. He is Professor of Human Factors for Health and Social Care at Staffordshire University, a Programme Director within Safety and Improvement for NHS Education for Scotland (NES) and a senior investigation science educator at the Health Services Safety Investigations Body (HSSIB). 

He is also an honorary professor at the University of Glasgow, where he completed his PhD in Postgraduate Medical Education in 2004 and where his studies were focused in the area of human factors.

Human factors, as defined by Bowie, involves the study and improvement of work systems to make things easier, safer and more efficient. Often, human factors are out of the hands of those they affect and risk leading to harm if left unchecked.

“I tend to have worked in relatively senior advisory and leadership roles around the quality and safety of healthcare,” he says. “A lot of the time, this involves working in large-scale projects with clinicians, anaesthetists, pharmacists, GPs and those involved in primary care.”

In the past 15 years, Bowie has been focused on raising awareness of human factors within the healthcare workforce. His work has covered virtually all roles in healthcare, stretching from educational supervisors in a training environment to those who head up patient safety and quality improvement at an organisational level.

As part of his invaluable work investigating the impact of human factors on patient safety, Bowie and colleagues carried out a walk-through talk-through analysis, shadowing a clinical team during the morning surgical ward rounds, to gain an insight into the issues that may impact outcomes for patients. 

The aim of this was to test its feasibility and usefulness in capturing ‘work-as-done’ in complex clinical environments. For the duration of the analysis, he observed multiple surgical ward rounds across three hospitals in the North East of England.

The ward round environment

“A lot of what we do from a policy, education and practice point of view around patient safety is embedded in concepts and theories which are potentially out of date,” he says.
“It’s a bit of a long haul and to try and update, modernise that.

“But having a role in NES is pivotal because it allows you to both have a reach and an influence around that. Engaging with RCSEd in Edinburgh, for example, is one way of doing that.”

To explore more about human factors, Bowie’s walk-through talk-through analysis involved shadowing a clinical team as they carried out a specific activity – in this case, the morning surgical ward rounds.

Bowie collected data by observing and interacting with a clinical team using a specific assistance-based framework to guide him.

“I didn’t have a set plan,” he says, “other than just to see what I saw, collect multiple perspectives from different team members and see what was going on. What was working for them? What enhanced their performance?”

Piecing the puzzle together 

One of the first issues to come to light was that the team were frequently burdened with secondary tasks – such as data collection – and this interfered with their workflow.

“It quickly became apparent after a few hours that a lot of this was quite challenging, it was very complex… Because [the team] were carrying the brunt of the data collection, and inputting the data into the patients’ records.”

Bowie also noticed an element of fragmentation in how the clinical team made certain decisions. Specifically, trying to piece together what treatment the patient had received previously. He says: “I reckon a significant proportion of the conversation was around trying to understand the rationales behind previous decision making.”

He found that a lack of a “joined-up” approach risked wasting the team’s time, as focus was placed on what the patient’s previous team hadn’t done.

In another instance, a team member revealed that the hospital didn’t have enough laptops for each member, telling Bowie that the hospital’s IT department doesn’t see it as a priority. He notes that this poses potential issues for patient dignity.

“I’m there as a neutral, a non-clinician, as an observer,” Bowie explains. “It was quite clear to me that regardless of what the team did, it was very difficult to protect patient confidentiality and to provide dignity to patients in very extreme, very sensitive situations.

“What the solution is to that, I don’t know, but it highlighted an issue.”

‘Suboptimal’ medical equipment

Though the identified factors may seem small, when they occur daily with no plan to end them, it’s easy to see how the ward rounds system can run into bigger issues.

Bowie points out how some factors contributed to a more physically demanding work environment. Stands that doctors would use to place laptops on were ineffective as they were unable to be adjusted.

“Some of them they couldn’t see over, you couldn’t adjust them so that you could see in front of you when you’re moving them… Some didn’t fit in the rooms,” he says.

“These were the things that I would say would be degrading people’s performance, because they’re a distraction or an irritation, and sometimes a downright risk as well.”

This notion also extends into surgery. Bowie specifies that surgical tools are generally designed for male hands, not female. This can have both short-term and long-term consequences, for example, having to adopt certain positions or stances, or
as serious as being at a greater risk for musculoskeletal disease.

“Bottom line, there are serious ramifications to medical equipment not doing the job as it was supposed to be done,” he says. “Those are the implications of suboptimal design. The whole thing is about understanding – more meaningfully – the nature of surgical safety and of healthcare safety in general.”

What improvements can be made?

Based on his work observing surgical ward rounds, how would Bowie recommend fixing these issues? Improving the technology needed for teams to do their job effectively is a priority  – basic amenities, such as ensuring Wi-Fi is accessible to the wards and providing enough laptops. 

Looking back on the walk-through talk-through analysis, however, he acknowledges that different factors can contribute to how a surgical ward round functions. Factors like the clinical condition of a patient, or the skill level of a team member, can cause the process to vary.

In the end, the most important way to begin to address these issues is to “close the gap” of knowledge on human factors. “We really need to modernise what surgeons are taught about safety. Update curricula, update policies and update practice,” he advises. 

Though there is a demonstrated interest in human factors from the World Health Organization (WHO), from professional bodies and from regulators, the main hurdle is finding the right resources.

“We know there’s a strong interest,” Bowie explains. “The difficulty we have is trying to get it embedded in everyday practice. For that you need policy and you need resources. That’s the bit we’re lacking at this moment in time.”