01Principles and purposeThe professional or clinical skill and the decisions it supports.
Human factors studies how people interact with tasks, technologies, environments and organisations. Error is rarely explained by individual knowledge alone. A wrong-dose event may involve similar packaging, interrupted calculations, inaccessible patient information, staffing gaps and a checking process that cannot detect the error. Naming these interactions does not remove professional accountability; it creates more effective prevention than telling staff simply to be careful.
Performance is adaptive. Clinicians trade thoroughness against urgency, coordinate around missing resources and create workarounds to deliver care. These adaptations often keep systems functioning but can become hazardous when conditions change. Examine work as done: who had which information, what cues were visible, how workload and time pressure shaped choices, and what barriers failed. Avoid hindsight bias, because the eventual outcome was not known to the people acting at the time.
Controls differ in strength. Removing an unnecessary hazardous step or engineering incompatible connectors usually changes behaviour more reliably than a warning label. Standardisation, forcing functions, decision support, independent checks and physical separation can help when matched to the failure mode. Education and reminders remain useful but degrade under pressure. Layer controls so one lapse does not reach the patient, and test whether the design creates delays, alarm fatigue or migration to a new workaround.
Teams maintain safety through shared situation awareness and psychological safety. Briefings establish goals and threats; call-outs make changes visible; closed-loop communication confirms critical instructions; graded assertiveness lets concern escalate. Leaders should invite dissent and respond constructively. A junior who detects a mismatch needs a clear route to stop and escalate. Hierarchy becomes dangerous when it suppresses data rather than coordinating expertise.
After an incident, attend first to the patient, family and staff and fulfil openness and reporting duties through local policy. PSIRF promotes proportionate system-based learning rather than automatic root-cause narratives for every event. Select a response that can answer a focused safety question. Map contributory factors, identify where defences failed and design improvements with owners and measures. A recommendation such as “remind staff” is incomplete until its mechanism and effect are tested.
Key points
- Patient safety incidents arise from interactions across a work system; look beyond the last person who touched the process to understand why harm became possible.
- Human performance varies with fatigue, workload, interruption, unfamiliarity and competing goals; design checks and escalation around this predictable variability.
- When risk is immediate, make the patient safe first, call for help, preserve essential evidence and communicate openly through local procedures.
- Use strong controls where feasible: remove the hazard, constrain the wrong action, standardise critical steps and make status visible before relying on memory or training.
- Checklists work when tied to meaningful pause points, current information and team dialogue; tick completion without engagement creates false reassurance.
- Report hazards, near misses and harm through local systems, recording observable facts, patient impact and actions without speculation or blame.
- Learning requires follow-through: identify contributory conditions, agree owned improvements, measure whether work changed and watch for new risks.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Fatigue, high workload, interruptions, noise, unfamiliar teams, poor lighting and time pressure increase variability and need compensating controls.
Near misses, repeated workarounds, frequent overrides and staff unease can reveal system drift before patient harm occurs.
Similar names, packaging, screens or device modes make the selected item look plausible while being wrong.
Fixation, fragmented information and unclear roles can make teams miss deterioration or duplicate incompatible actions.
A team member raises a discrepancy but is dismissed or cannot identify who is accountable, weakening the final defence.
Actions focused only on retraining, policy circulation or individual blame often leave the original conditions unchanged.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Immediate safety assessment - Why
- Identify current patient harm, ongoing exposure and anyone else at risk.
- Interpretation and limitations
- Stabilise, stop the hazardous process and escalate clinically before beginning a detailed investigation.
- 02
Chronology and work-system map - Why
- Reconstruct what happened using records, artefacts and accounts across person, task, tool, environment and organisation.
- Interpretation and limitations
- Separate observation from interpretation and avoid judging earlier decisions with information available only later.
- 03
Barrier analysis - Why
- Identify intended prevention, detection and recovery controls and how each performed.
- Interpretation and limitations
- A missing barrier, unusable check or common bypass suggests a design target more specific than generic vigilance.
- 04
Team communication review - Why
- Examine role clarity, handover, escalation and whether concerns could be voiced and heard.
- Interpretation and limitations
- Communication failure may reflect hierarchy, workload or tool design, not simply an individual’s phrasing.
- 05
Control-strength assessment - Why
- Match proposed action to the failure mode and place it as high as feasible in the control hierarchy.
- Interpretation and limitations
- Elimination, constraint and design changes are generally more dependable than memory-dependent warnings alone.
- 06
Outcome measurement - Why
- Define process and balancing measures, owner, deadline and review cycle.
- Interpretation and limitations
- Verify that the control is used, reduces the target hazard and has not displaced risk elsewhere.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseWrong-concentration near missA nurse notices that a look-alike ampoule of a higher concentration has been selected immediately before administration; no drug reaches the patient.+
- 1Stop administration, confirm the patient is unharmed, secure the ampoule and prescription details, inform the responsible clinician and manage any continuing stock risk immediately.
- 2Record factual chronology and report the near miss, including location, workload, storage, packaging, electronic display and how the discrepancy was detected.
- 3Map defences: selection, preparation and check stages; identify why the wrong item was easy to choose and why the final check succeeded this time.
- 4Implement an owned control such as physical separation or purchasing and system constraints, then audit selection errors and staff workarounds to verify risk reduction without delaying urgent care.
02Applied approachEscalating a dismissed concernA junior believes the planned procedure is for the wrong side, but the list and consent form disagree and the senior asks the team to continue.+
- 1Use clear graded language to state the exact mismatch and request an immediate stop.
- 2Recheck identity, source documents, imaging and patient confirmation through the local invasive-procedure standard rather than negotiating from memory.
- 3If disagreement persists, escalate through the named clinical and organisational route while the procedure remains paused.
- 4Document the discrepancy and resolution, report the hazard if appropriate and review why conflicting information reached the stop point.
03Learning processMedication omission after transferA time-critical medicine is omitted after a ward move because two teams each believed the other had prescribed it.+
- 1Assess and treat any patient consequence and establish current prescribing responsibility.
- 2Build a timeline of transfer, electronic access, verbal handover and workload without assuming the last user caused the omission.
- 3Identify the missing ownership and reconciliation barriers and choose a feasible system control with explicit acceptance at transfer.
- 4Measure timely medicine reconciliation and omissions after implementation, checking for new delays or duplicated prescribing.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Track implementation of every improvement with a named owner, due date and process measure rather than closing the incident at recommendation.
- Use near-miss and hazard reports alongside harm incidents because they reveal controls and drift before worse outcomes.
- Review balancing measures, including delay, alert fatigue and workload transferred to another team.
- Repeat observation of work as done after a change; written policy compliance does not show whether the redesigned process is usable.
- Share learning with affected staff and patients through approved processes, including what changed and what remains uncertain.
- Escalate recurring hazards that exceed local control to organisational and national reporting routes when applicable.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Near misses show resilience
The recovery step that prevented harm is evidence about a useful barrier, while the preceding chain identifies where prevention can improve.
Hindsight changes perceived probability
After harm, warning signs appear obvious; reconstruct what information and options were actually available at each moment.
Checks need independence
A second person who repeats the first person’s assumptions is not an independent check; define the critical elements to verify.
Standardisation has limits
A standard can reduce unwanted variation, but clinicians need an explicit route for justified deviation and escalation in unusual patients.
Culture is behavioural
Psychological safety is demonstrated when staff can raise concerns, leaders respond, and reported hazards produce visible learning.
Assessment language
In AKT and interview questions, favour system controls and measurable follow-through while still addressing immediate individual clinical duties.
Workarounds are diagnostic
Repeated deviation from a policy may reveal that resources, sequence or interface make the intended process impractical.
Balancing measures prevent displacement
A change that reduces one error but delays treatment or creates duplicate work needs redesign rather than uncritical spread.
07Common pitfallsFrequent interpretation and management errors.
- 01
Beginning an incident review before securing the patient and stopping continuing exposure.
- 02
Equating the last visible error with the full cause and ignoring task, tool and organisational conditions.
- 03
Writing “staff reminded to be vigilant” as the only preventive action.
- 04
Using a checklist without protected pause, current data or team participation.
- 05
Suppressing a junior concern because hierarchy is mistaken for evidence.
- 06
Closing an action without measuring adoption, effect and unintended consequences.