Human Factors

A systems approach

Applying a Human Factors Framework

Take a moment to read over examples of the possible contributory factors that can combine to cause significant events


e.g. Patient & Individual Practitioner Factors; Social & Personality Issues; Physical & Psychological Characteristics; Skills, Knowledge & Training


e.g. Job Task Demands & Complexity; Task Technology Usability & Availability Issues; Decision-making, Attention Levels, Interruptions & Distractions


e.g. Organisational & Management Factors; Physical Environment Factors; Teamwork & Communication; Institutional Context Factors

Click on the headings below (People, Activity, Environment) to view examples of each:

Examples of the Human Factors Framework

Take a moment to read over examples of the possible contributory factors


Individual e.g. physical issues, psychological issues, social and domestic issues, personality issues, cognitive factors, competence skills, attitudes, risk perception, education and training.

Team e.g. role congruence, leadership, support and cultural factors, communication.

Patients e.g. clinical condition, physical factors, social factors, mental/psychological factors, interpersonal relationships.

Other e.g. hospital policy, social services.


Complexity of Process or Work

Guidelines, Policies and Procedures e.g. not up-to-date, unavailable, unclear/unusable, not followed.

Procedural/Task Design e.g. level of complexity, workload, poorly designed.

Equipment e.g. displays, integrity, positioning, usability lacking.


Work Setting e.g. administrative factors, design of physical environment, environment, staffing, workload and hours of work, time.

Organisational e.g. organisational structure, priorities, externally imported risks, safety culture.

Communications e.g. verbal, written, non-verbal systems.

Education and Training e.g. competence, supervision, availability/accessibility, appropriateness.

Societal, Cultural and Regulatory Influences

Case Study

Take a moment to review and reflect on this brief summary of a significant event

View Case Study

A GP surgery decided to have their health visitor trained to administer childhood immunisations to ease their practice nurse's workload. The health visitor started working under the supervision of another qualified health visitor after completing her training. A three-month old girl attended one of the first 'new' immunisation clinics to receive her second booster. The clinic was very busy. The MMR and DTP/Hib vaccinations were placed on the same table. The health visitor picked up the 'wrong' vial while attempting to answer some of the mother's general questions and accidentally administered the MMR rather than the required DTP/Hib vaccine. She realised her error when performing the 'double check' of the vial with her colleague AFTER administering the vaccine. The health visitor immediately informed the GP and parents, and apologised for ' accident...'. The GP and health visitor contacted the local hospital paediatric department to check for likely complications and re-assessed the child on several further occasions. The child did not suffer any harm and received the appropriate vaccination a few days later.

Actual or Potential Impacts: distressed parents and staff, potential (low) risk of harm to baby, need to access expert advice on risks, potential complaint and adverse media publicity, need to reassure and apologise verbally and in writing to parents.

Contributory Factors and Interactions

The framework below outlines the contributory "People", "Activity" and "Environmental" factors that may have influenced the cause of this significant event.

Click on the headings below (People, Activity, Environment) to view examples of each:


The health visitor had just finished her training. She had adequate knowledge, but required additional experience and supervision.

She was distracted during the process by the parent's questions.

The second health visitor had assumed the correct vaccine would be administered.

Staff felt under pressure because of the busy workload.

Staff go into 'automatic pilot' mode.


There was only one table for all vaccines and the room was too small to accommodate health care workers, the patient, and several family members.

The different vaccines looked very similar.

High volume of patients and vaccinations.


Increased workload resulted in decision to create new roles and duties.

Efficiency savings resulted in different age groups attending a combined clinic for different types of vaccinations rather than vaccination-specific clinics.

Lack of a formal protocol outlining the system for safe management of the whole vaccination process, including double-checking with colleague and parent/carer.

The practice wrongly assumed that the local primary care organisation would have trained both health visitors to develop and follow a relevant protocol.

Learning Issues and Action Plan

Review and reflect on some potential Learning Issues

Review and reflect on some potential Learning Issues and the Action Plan for Improvement below. You may think of other system improvements that are needed to minimise the chances of the event happening again.

Click on the headings below (Learning Issues, Action Plan) to view examples of each:

Learning Issues

(Individual and Practice Level)

Existing immunisation system failed to properly protect the safety of a child - no formal, reliable system in place.

Because of this system flaw, human error was inevitable.

Staff administering vaccinations should be empowered to develop, implement and follow a systems based protocol.

There was a lack of communication between staff and between staff and parents.

The combined clinics and volume of associated workload contributed to the error.

Assumption made that the immunisation training body would have developed a protocol and would be responsible for this.

Responsibility and liability is a practice issue.

Action Plan

(System Improvements)

The practice sent a written apology to the family, informed them of the investigation and informed them that the investigation led to a new immunisation system being introduced.

A system protocol was developed, laminated, and placed in the room used for immunisation. It was added to the practice protocols folder and the new staff induction pack.

In the fridge, one designated and clearly marked shelf would hold all the childhood vaccinations.

A wall-mounted sign was introduced to remind staff to keep work surfaces uncluttered to provide a good overview of different vaccines, which should be clearly separated.

Separate designated immunisation clinics were introduced to allow more time for vaccination and recording.

The issue will be monitored at SEA meetings until the new system is embedded in routine practice.

Identify Contributing Factors

Now reconsider the event with which you have been personally involved.

Based on the Human Factors framework:

What were the People, Activity and Environment factors that may have led to this significant event?

You may now have a better understanding of some of the system-based factors that contributed to your event.

For some of these issues you may be able to make immediate improvements, while for others you may need to include the wider team.

Consider what changes you can potentially make to minimise the chances of this event happening again.

Remember that to gain a fuller understanding of the contributory factors influencing the event, you may need to undertake a more in-depth analysis with the wider team.

Thinking about how some or all of the factors combined to influence your event, re-assess if your original judgement about your role in the event would now change.

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