Article Text

Download PDFPDF
G503(P) Initial results from a pilot enabling frontline staff to identify human factors in patient safety incidents on a paediatric intensive care unit
  1. H MacGloin1,
  2. P Knight2,
  3. E Haxby3,
  4. P Mortimer4,
  5. L Lofton1,
  6. M Lane1,
  7. A Desai1,
  8. M Burmester1
  1. 1SPRinT Paediatric Intensive Care Unit, Royal Brompton and Harefield NHS Trust, London, UK
  2. 2Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
  3. 3Clinical Risk, Royal Brompton and Harefield NHS Trust, London, UK
  4. 4Children’s Services, Royal Brompton and Harefield NHS Trust, London, UK


Background and aims Human factors (HF) is the science of human performance within a given system.1 It was adopted by healthcare from safety critical industries to improve patient safety. HF training is recommended by the General Medical Council (GMC), World Health Organisation and Royal Colleges.2 3 Despite the importance of HF to patient safety, there is a relative paucity of research on how to incorporate HF perspective within existing patient safety reporting systems such as Datix.

Aims To analyse the contribution of HF within Datix reports submitted from the Paediatric Intensive Care Unit. To enable a HF perspective in patient safety incidents (PSI) within the paediatric directorate.

Methods PICU Datix submitted between 1.4.2007–1.4.2015 were analysed according to HF categories which were devised according to “Implementing Human Factors in Healthcare: How to Guide”.4 A drop-down menu on Datix was developed to enable staff to choose a HF at the time of reporting. The new system became live from 1.10.2015. The effect of the change on reports submitted by PICU between 1.10.2015–1.12.2015 was analysed.

This work was registered as a quality improvement initiative.

Results 1946 PICU Datix were submitted from April 2007–April 2015. 329(20.3%) reported HF. Communication (10.4%, n = 203), was the most commonly cited HF.

127 PICU Datix were submitted between 1.10.2015–1.12.2015. 48 (37.8%) attributed a contributory HF, most 19 (15%) cited communication.

Conclusion Simple changes to existing safety tools can enable a HF perspective to overcome wrong assumptions about error causation. The relevance of HF is still not fully embraced within reports but within 2 months, HF reporting has increased since the change in reporting system and there has been subsequent trust-wide implementation of HF within Datix. Further research is required as we strive to improve the safety culture of teams and organisations and a human factors perspective will feature increasingly as healthcare’s socio-technically complex system is better understood.


  1. DoHclass="RefAuthor"> Human Factors Reference Group Interim Report, National Quality Board, March 2012

  2. GMC Academy of Medical Royal Colleges July 2015 “Developing a framework for generic professional capabilities” A public consultation

  3. WHO Patient Safety Curriculum Guide: Multi-professional edition 2011

  4. Carthey, J Patient Safety First: The “How to Guide” for Implementing Human Factors in Healthcare Version 1 2009

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.