Design is the key for effective human factors
In a recent famous
case, one surgeon and two anaesthetists were said to be
anaesthetising two patients at the same time; this would be risky and
unnecessary for patients to be anaesthetised for longer than
absolutely essential. It is unethical.
https://theworldnews.net/gb-news/derek-mcminn-patients-put-in-danger-so-scandal-hit-surgeon-could-perform-two-operations-at-same-time
The question is: how
did this even happen? There must be policy in place to prevent this.
There must have been people who could and should have questioned this
and prevented this. Sure. Let’s assume we had policies and people
in place – do they prevent for sure two patients being
anaesthetised for the same one surgeon at the same time? No.
It happened because
there was the structure, infrastructure and facilities to do it.
In UK hospitals
there is something called the anaesthetic room which is separate from
the operation theatre. This means for one surgeon, there could be a
patient anaesthetised inside the operation theatre and another
patient anaesthetised in the anaesthetic room.
This is a fairly
unique UK NHS practice. Historically, the subsequent patient was
brought into the anaesthetic room and the process of anaesthesia
began or anaesthesia given when the patient on the table in the
operation theatre was nearly done. This was thought to be efficient.
It worked when the so called ‘registrars’ both anaesthetic and
surgical were experienced. This anaesthetic room concept was then
followed by UK private hospitals.
The presence of the
anaesthetic room means that it would be physically possible for two
patients to be under anaesthetic simultaneously for a single surgeon.
Recently, when
designing the theatres of a private hospital, we argued for not
having an anaesthetic room and prevailed.
This means that in
that private hospital which does not have an anaesthetic room, there
is no possibility of two patients being under an anaesthetic at the
same time for a single surgeon because there is no physical
infrastructure/facility that enables/allows it. No policy or
person(s) would have been able to achieve this.
We cannot design a
problem to be built into a system and then expect policies and people
to overcome it consistently.
Design is the
fundamental for human factors – people and behaviours are simply an
add on bonus.
© Hemadri