Evolving Healthcare and Improving Patient Safety

James Reason's Swiss Cheese Model of Error Causation Reason.J; (2000) Human error: models and management BMJ 320:768
James Reason's Swiss Cheese Model of Error Causation

About human factors

‘Human factors’ is a term used to describe everything outside our technical skills and knowledge that affects our ability to work well and safely. It includes examining how we interact with our work environment; our behaviour and communication with others in the
workplace; our ability both as an individual and as part of a team to cope under pressure
and respond appropriately to interruptions, crises and unforeseen challenges; and the
particular culture, resources and structures within our own clinical environment. A simple
way to view human factors is to think about the three aspects: the job, the individual and
the organization and how they impact on people’s health and safety related behaviour
(Health and Safety Executive, 1999; www.hse.gov.uk/humanfactors).

Human error is common in medicine and may occur as a result of any of the above factors; for example, making a rash decision because you are feeling time-pressure, or not speaking up when you are uncomfortable with a colleague’s decision – or even something as simple as mispronouncing a patient’s surname during handover.

The Harvard Medical Practice Study (1991) revealed that 1 in every 200 patients admitted to acute care hospitals died as a direct result of medical error. This study provoked similar work in other healthcare systems, including the UK where it has been estimated that approximately 40,000 patients die every year as a result of human error. Obviously the most important impact of human error is on the patients themselves, but there is a significant cost-implication in terms of litigation, and each adverse event leads to an average of 8.5 additional bed days (Charles Vincent ,BMJ [2001]).

Human factors training seeks to explain and demonstrate the varying interactions between individuals, teams, equipment and environment, and most importantly it provides strategiesto change our behaviour so that we are less likely to make errors and harm patients.

There is an obvious moral imperative for undertaking human factors training in healthcare: we are making mistakes that are harming our patients, and we must do better. Human factors training has improved safety in many other industries and the lessons learned from these so-called ‘high reliability organizations’ (HROs) are eminently transferrable to healthcare. Our training modules have been designed to help healthcare professionals learn from past mistakes and provide strategies for use in the workplace which will help reduce harm to our patients. You will find references to stories about error from the airline, rail and nuclear power industries, as well as healthcare, which will inform improvements in your everyday practice.


Brennan, TA, & LL Leape, ‘Adverse events, negligence in hospitalized patients: results from the Harvard Medical Practice Study’, Perspectives in Healthcare Risk Management, Vol. 11, Issue 2, 1991, pp. 2–8.
Vincent, C, G Neale, & M Woloshynowych, ‘Adverse events in British hospitals: preliminary retrospective record review’, British Medical Journal, Vol. 322, Issue 7285, 2001, pp. 517–519.

Further reading

Reynard, J, J Reynolds & P Stevenson, Practical Patient Safety, Oxford University Press, Oxford, 2009.

World Health Organization (WHO), ‘Human Factors in Patient Safety: Review of Topics and Tools’, Report for Methods and Measures, Working Group of WHO Patient Safety, WHO, 2009.