HUMAN FACTORS ASSIGNMENT

CASE SCENARIO 5

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Table of Contents
1. Introduction....……………………………………………………………………………..3

2. Section 1…………………………………………………………………………………..4

3. Section 2………………………………………………………………………………….6

4. Section 3………………………………………………………………………………….7

5. Section 4………………………………………………………………………………….9

6. Conclusion… …………………………………………………………………………….11

7. References… …………………………………………………………………………….13
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1. Introduction

The current study explores professional qualities, for instance, candour, ethical

decision-making, emotional intelligence, and resilience in the professional healthcare

provider. Furthermore, it also demonstrates that with the help of the current

assessment, it has also been understood what the attitude should be experienced while

working with others and helps to explore the need for team dynamics, developing

leadership skills as well as the better workplace culture so that the better attention can

be provided to the patient. Furthermore, the importance of NMC and NRL codes has

been discussed throughout the research.

The assessment is divided into four main parts.

 The first section is based on the illustration of the broad knowledge and

understanding related to human factors and their influence on risk, along with the

decision-making to provide safety to the patients with the help of crucial literature

and swiss cheese model.

 In the second section, the concept related to uncertainty and risk management

has been evaluated and analysed with the help of in-depth knowledge of

evidence-based strategies to manage self and others.

 The third section will help critically discuss the organisational issues to assess,

monitor, and evaluate the human factors and their impact on care. It will also

include the principles related to candour, courage, and transparency identifying

the effect of individual behaviour.

 The fourth and last section will help to significantly reflect on the responsibility of

health care professionals to discover, report and manage the risks, close errors,
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adverse events, mistakes in their practice, and significant serious incidents,

along with how to implement the knowledge from these events.

Each section has done critical analysis highlighting the main events as per the

provided case study/ scenario.

2. Section 1

Human factors refer to a broad field that deals with the variety of problems

relating to how people interact with their surroundings. By considering the elements that

affect how patients, employees, and other stakeholders interact with the environment,

human factors can be used to enhance safety and lower hazards in the healthcare

setting (Buheji and Buhaid, 2020). The primary human factors that are present in this

case scenario are unstable environment, substance abuse, undiagnosed mental illness,

the stress of traumatic life events, poor physical health, limited access to healthcare

services, and social factors such as social isolation and lack of social support. Even

though he had a supportive family, Jon chose to isolate himself from everyone, along

with all the other human factors, which led to the risks that worsened the situation.

Human factors are important in both the risk of medical errors and the design of

healthcare facilities and processes (Carayon and Hoonakker, 2019). Furthermore,

human factors can have an impact on the quality of communication between healthcare

professionals as well as between healthcare workers and patients, which can have a

direct impact on patient safety (De Hert, 2020). In the given case scenario, human

factors impacted the events that occurred. The lack of coordination among Jon, His

parents, and the healthcare staff, as well as the lack of proper diagnosis for his mental
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illness of Jon, led to the delay in treatment. Besides this, the events are heavily

influenced by social factors such as social isolation harming mental and physical health

of Jon. Overall, the human factors of this case scenario impacted negatively on the

events that occurred.

According to the Swiss Cheese model, any accident or incident is created by a

string of loopholes in the protective layers that surround an individual, which is

compared to slices of Swiss cheese. Each slice of cheese represents a separate layer

of security, including policies, procedures, employees, and the environment. An

accident or mishap might occur when the holes in the cheese slices line up (Carayon et

al., 2020). In the case scenario, there were several loopholes such as the

miscommunication between Jon and his parents regarding his situation. The inefficiency

of the healthcare provider in diagnosing and treating the suicidal anxiety of Jon and

involving his parents in Jon’s care plan. The patient safety procedures were not followed

properly, and the environment that Jon existed in was stressful and depressing for him.

All these loopholes aligned together which led to putting patient safety at risk. A whole

systems approach assists in analysing a situation by looking at the interaction between

all the different components of a system, such as the people, processes, and

environment. This holistic approach allows us to identify the organisational factors that

may be contributing to patient safety or clinical incidents. By looking at the system as a

whole, we can assess the impact of workplace culture on patient safety and identify

areas for improvement. Furthermore, this approach can help us to identify the root

causes of incidents and take a proactive approach to prevent them.

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3. Section 2

The case scenario involved the risk of self-harm or suicide, physical health

problems, substance abuse, social isolation, financial or work-related difficulties, and

the risk of relationship problems. In addition to that several uncertainties were involved

in the case scenario such as the long-term consequences of untreated depression on

the mental and physical health of Jon, The potential for depression to worsen over time

when left untreated, the effectiveness of treatments for depression and anxiety, such as

medication and psychotherapy, the potential for depression and anxiety to impact other

areas of Jon’s life, such as work, family and relationships and the probability of relapse

or recurrence of depression and anxiety symptoms. These should have been managed

by

 Ensuring that quality mental health care, including access to mental health

specialists and therapists, is accessible to Jon.

 Jon should have joined a support network for the patients affected by depression

and anxiety, such as peer-support groups, online forums, and support lines.

 He should have been encouraged to make lifestyle changes such as exercising

regularly, eating a balanced diet, and having a proper sleep routine.

 He should have learned techniques for managing stress, such as deep breathing,

yoga, and mindfulness.

 The healthcare team should have monitored Jon on regular basis and follow-up

care should be provided to him if required.

According to recent studies, Cognitive Behavioural Therapy (CBT) is an effective

treatment for depression and can lessen suicidal ideation in people with untreated
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depression. According to (Gardiner et al., 2022) CBT was considerably more effective

than standard treatment in lowering suicide ideation in patients with untreated

depression. CBT was also demonstrated to not only lessen suicidal ideation but also to

alleviate depression symptoms. Interpersonal therapy (IPT) has also been shown to be

an effective treatment for undetected depression. According to (Karimi et al., 2021) IPT

was beneficial in lowering suicidal ideation in patients with untreated depression. Also,

IPT was observed to lessen depression symptoms much more than the standard

treatment. In addition to CBT and IPT, (Larouzee and Le Coze, 2020) explained that

psychoeducation can be particularly effective in lowering suicide ideation in patients

with untreated depression. Psychoeducation proved beneficial in reducing suicide

ideation among individuals with untreated depression. Psychoeducation was

demonstrated to lessen suicidal ideation and improve depression symptoms. CBT, IPT,

and psychoeducation have all been demonstrated to be effective evidence-based

methods for lowering suicide ideation in patients with untreated depression.

4. Section 3

Organisational issues can have a huge impact on the risk assessment, risk

monitoring, and overall evaluation of the human factor in the case scenario. Poor

organisational practices such as a lack of communication among the parents of Jon and

healthcare staff, the unwillingness of healthcare providers and GP to recognise or

respond to signs of distress, and inadequate mental health policies of the mental health

ward, all lead to a failure to identify and address risk factors associated with suicidal

ideations of Jon. Inadequate training of hospital staff in the recognition of mental health
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issues and inadequate access to mental health services made the situation of Jon

worse as his mental illness remained undiagnosed throughout the case which lead to

the situation where Jon tried to attempt suicide. Furthermore, a lack of understanding

and awareness of mental health issues within an organisation led to negative attitudes

and stigma surrounding mental illness and made it even more difficult for Jon to seek

help. Ultimately, organisations need to create a safe and supportive environment where

mental health issues can be discussed openly and where individuals can access

appropriate support and services (Quick, 2022). Organizations must ensure that they

have adequate processes in place to analyse and mitigate risks to ensure patient

safety. This should contain clearly defined roles and duties for each team member, as

well as a clear and consistent risk assessment and risk management approach. Staff

members should be sufficiently trained in risk assessment and management, and a

clear procedure for reporting and monitoring risks should be in place (Smitth and

Plunkett, 2019).

Furthermore, organisations should assure that sufficient resources and time are

available for risk assessment and management. Lastly, organisations should ensure

that all healthcare providers communicate effectively so that risks can be detected and

managed immediately and accurately. Incident reporting is an important component of

any organization's duty of candor. All incidents, no matter how minor, must be recorded

and documented since they may reveal a possible safety issue or system failure

(Staines et al., 2021). Organisations can detect patterns and trends by carefully

documenting incidents, which can aid in making the decision and improve

organisational safety. Organisations must be open and honest with patients and their
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families about the care and treatment they receive under the duty of candour. This

includes disclosing pertinent information about any incidents that may have occurred,

such as errors or blunders. Being upfront and honest about incidents ensures that any

problems are addressed as soon as possible and correctly. Wiegmann et al. (2022)

further explained that it is also critical to properly analyse incidents and take any

necessary corrective measures to prevent repeat recurrence. Organisations

demonstrate their commitment to the duty of candour and patient safety by taking

appropriate action. Concerning incident reporting, candour is speaking up about any

concerns or issues that may arise, without fear of judgment or consequence, courage is

about speaking up and having the confidence to do the right thing in the face of

difficulties or challenges While transparency is about providing accurate and complete

information about an incident, without withholding or hiding anything. The absence of

these basic principles, in the case scenario, negatively impacted patient safety and risk

management.

5. Section 4

The scenario presented highlights the critical importance of incident reporting

and the need for healthcare professionals to be vigilant in identifying, reporting, and

managing risk, near-miss events, and adverse events in clinical practice. As mentioned

in the study by Williams et al. (2019), incident reporting is the process of documenting

any unexpected or unintended event or situation that has occurred during the delivery of

care. Furthermore, World Health Organization (2018) has also mentioned that it is an

essential part of good clinical governance and provides a mechanism for healthcare
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organisations to learn from incidents, identify areas for improvement, and prevent future

harm. As per the Nursing and Midwifery Council (NMC) Code of Conduct stipulates that

healthcare professionals have a duty to ensure they practice safely and effectively. This

includes recognising and reporting any risks to the patient, taking appropriate action to

mitigate these risks, and promoting a culture of openness and learning. In the study by

Dinnen et al. (2022), it has been mentioned that Healthcare professionals must be

aware of the NMC's platforms for reporting incidents, such as the National Reporting

and Learning System (NRLS) and the Strategic Executive Information System (SEIS)

and understand their role in reporting incidents.

In the scenario presented, the healthcare professionals involved had a

responsibility to report the incidents, such as Jon's suicidal ideation and subsequent

overdose, to the relevant authorities. However, there were missed opportunities for

timely intervention and support due to inadequate reporting and communication, as

mentioned by Anderson et al. (2019). Additionally, it has also been noted that Jon's

parents were not adequately informed about his care plan, and he was discharged from

the hospital without adequate follow-up care. This highlights the need for effective team-

working and clear communication between healthcare professionals, patients, and their

families. In addition to following policies and procedures around incident reporting,

healthcare professionals must also reflect on their own practice and identify areas for

improvement, as depicted in the study by Lavender et al. (2019); Murray et al. (2018).

The incident presented in the scenario could have been a learning opportunity for the

healthcare professionals involved, providing insights into how they could improve the

care they provide to patients with mental health issues (Sturman et al., 2017).
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Furthermore, it is essential to take a systems approach to incident reporting, examining

the root causes of incidents and implementing changes to prevent similar incidents from

occurring in the future.

Hence, it has been noted from the given case scenario that the incident reporting

is an essential part of ensuring patient safety and improving the quality of care

(Elmontsri et al., 2017). Healthcare professionals have a responsibility to identify, report

and manage risks, near-miss events, and adverse events in clinical practice. Moreover,

being a professional practitioner, it is essential to follow the NMC Code of Conduct,

understand the role of reporting platforms, and promote a culture of openness and

learning, as posited by Morgan and Parry (2017). By doing so, healthcare professionals

can learn from incidents and ensure that they are providing safe and effective care to

their patients.

6. Conclusion

In conclusion, this study has highlighted the importance of professional qualities

such as candour, ethical decision-making, emotional intelligence, and resilience in the

healthcare industry. The assessment has shown the need for professionals to

understand human factors and their influence on risk and decision-making, as well as

strategies for managing uncertainty and risk. It has also emphasised the need for critical

evaluation of organisational issues related to the impact of human factors on patient

care, together with the principles of candour, audacity, and clarity. The study has

explored the responsibility of healthcare professionals in classifying, reporting, and

handling risks, close failures, adverse events, mistakes in practice, and important critical

incidents, and has demonstrated the importance of applying learning from these events
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to improve patient care. The NMC and NRL codes have been highlighted throughout the

study, emphasising the importance of these codes in ensuring safe and effective

practice. Furthermore, with the help of Swiss cheese model, the incidence of system

disappointments, such as medical accidents within the case study has also been

analysed. Overall, the study has emphasised the importance of maintaining a culture of

safety in the healthcare industry, where professionals are empowered to report

incidents and learn from them to improve patient outcomes. The chosen scenario of a

medication error and the subsequent harm caused to the patient has served as a

reminder of the importance of maintaining high standards of practice and the

consequences that can occur when these standards are not met. Hence, healthcare

professionals must prioritise patient safety and learning.

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