The Pediatric Cardiac Surgery Inquest Report



Human factors analysis

Where should institutions focus their attention as they work to create mechanisms to identify errors, limit their impact, and prevent their recurrence? Persuasive evidence was presented to the Inquest suggesting that the field of human factors analysis provides some useful tools in making this decision.

Human factors analysis arose out of the study of accidents in the aviation industry. Studies of air disasters suggested that the majority of accidents did not result from technological faults or a lack of technical skills. Instead, the studies suggested that in addition to an underlying flawed system, the contributing factors or triggers for the disaster lay within the area termed human factors. This is the scientific discipline concerned with interactions among humans and other parts of a system in carrying out a purposeful activity. Human factors include leadership, teamwork, communication and decision-making.

These issues have also been identified as critical in medical mishaps. Leadership, teamwork, communication and decision-making are recurring themes in this Report. They are not side issues, not matters of mere personality difference, but central issues. Where these issues were not resolved, they often led to tragic results.

Human factor analysts suggest that the errors, incidents, critical incidents and accidents that arise from human behaviour can best be addressed in a systematic fashion through programs of quality assurance and error and risk management. These programs need to address the behaviour of people who might appear to perform at less than an optimal level. However, more importantly, these programs must address what are termed 'systemic issues', that is, problems that lie within the whole of the hospital or even the health care system itself.



Current Home - Table of Contents - Chapter 10 - Human factors analysis
Next A new approach to the handling of medical error at the HSC
Previous Hierarchy of the effects of errors
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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