Abstract

A hospice like any organisation, wants to provide an efficient, quality service which is safe and protects the wellbeing of those who provide it as well as those who use it. That requires an understanding of the components of the systems involved and the effects related to human interaction at different interface levels. This paper presents how following introductory training in Human Factors and introducing staff to the ‘Swiss Cheese’ model (Reason, 1990), multi-disciplinary Learning Events were developed within St Luke’s Hospice, Plymouth. These events, in line with Safety II thinking (Hollnagel, 2014) explore ‘what went well (www)?’ and what could be done better.

Learning events are ‘triggered’ at regular intervals for positive events but are also part of any incident follow up. These events are co-ordinated and facilitated by key personnel with an interest in Human Factors. Participants can be directly or indirectly involved with the service. The facilitators conduct exploratory work to gain some understanding of the organisational, physical and cognitive components of the task and pre-populate the defensive layers or ‘barriers’ in the system. During the learning events participants discuss and consider what makes the defensive layers effective but also any latent failures or factors within them that could contribute to an untoward event. From this an action plan in relation to improvements required is developed and recorded centrally with feedback provided to the Sign up to Safety steering group.

Employing an ergonomics and human factors systems framework enables a holistic exploration of how various components of a task and system interact. Introducing learning events which encourages this approach promotes more collaborative working relationships and can be used retrospectively and proactively. In this way, the service or system can be designed to fit human requirements, capabilities and limitations recognising the multiple interacting factors that contribute to safety.