Designing for Safety

The Swiss Cheese Model

Our understanding of human factors and situational awareness can be used to design and build in ‘fail-safes’, defences or processes into the system around us to identify and stop errors occurring as well as making it easier for us to do the right thing.

However, even with built-in safety measures adverse events can still occur as demonstrated by James Reason’s Swiss cheese Model. This demonstrates that if all the holes in the Swiss cheese line up then the adverse event or incident can still occur.

It is the same with communication, teamwork and leadership. In dentistry we are all taught how to work well with our teams, including our dental nurses and we know what makes a good team. However, time after time experienced teams make errors which can sometimes lead to adverse events. 

Some of those in dentistry include: 

• extracting the wrong tooth
• re-using dirty or unsterilised equipment
• overexposing a patient with x-rays
• inhalation of small instruments or crowns
• prescribing a patient a medication they are allergic to

Human Factors: Learning from other high risk industries

We mentioned in a previous article that Human Factors is relevant not only to healthcare but to many other safety critical industries. One of those is the airline industry and much of our learning about Human Factors and the processes we put in place to improve patient safety comes from that industry where a critical incident can cost not one, but many lives. 

Safety critical industries are areas of work where making an error has the risk of leading to a serious adverse event such as death or serious injury. Before it came into healthcare and dentistry, Human Factors was a big part of improving aviation safety following a number of high-profile accidents. One of those is the Tenerife air disaster of 1977. Please watch the following video for a summary:

Tenerife Airport Disaster | Deadliest Crash in Aviation History (youtube.com)

You may or may not be surprised that hierarchy as well as failure in communication and teamwork were significant factors leading to this terrible disaster. Hierarchy refers to a situation where people feel they can’t speak up in a critical situation because they are too junior or not in charge or where they feel that because of their status their views will be ignored. Hierarchies also exist in healthcare and a lot of work has been done over many years to ensure that everyone, no matter what their roles is, feels able to speak up if they notice something going wrong.

Just a routine operation

Please now watch the following video narrated by Martin Bromley about his wife Elaine Bromley who went into hospital for a ‘routine operation’.

Just a Routine Operation (youtube.com)

Hopefully you are starting to understand how often adverse events involve the failures of non-technical aspects of work such as communication, culture, teamwork, leadership and situational awareness.

We know from research that outcomes for patients are not purely based on the technical skills of healthcare workers. Take a famous study which observed surgical teams in theatres, some were given a rude surgeon, and some were given a polite surgeon. A rude surgeon reduced the performance of the anaesthetist by almost 30%. 

Take some time to consider the importance of these findings to a dental team and the relationships between dentists and other members of their team such as dental nurses or hygienists and therapists. 

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