Catherine Best, Practice Educator at Saint Catherine’s Hospice, Scarborough takes the opportunity to emphasise the importance of nurses understanding the impact of human factors on patient care, and when things go wrong, having the courage to speak up.

In 2021 the World Health Organization (WHO) published The Global Patient Safety Action Plan 2021–2030. Entitled: Towards Eliminating Avoidable Harm in Health Care .

This Action Plan recognises that:

‘Today, patient harm due to unsafe care is a large and growing global public health challenge and is one of the leading causes of death and disability worldwide. Most of this patient harm is avoidable’ (WHO, 2021).

It is with this challenge in mind that this blog will focus on the importance of nurses understanding human factors and how this knowledge can contribute to ensuring the delivery of safe and effective care.

Accessing educational opportunities is a fundamental role of registered nurses and nursing associates, indeed all health professionals and is emphasised in the report Improving Safety Through Education and Training published by the Commission on Education and Training for Patient Safety. This report outlines the importance of a culture of shared and life-long learning, the emphasis being on the importance of safe patient care.

Ensuring the nursing workforce continues to be educated, is therefore essential if we are to maintain and improve the delivery of high-quality patient care. As nurses we are now required to become self-directed, self-determined, life-long learners and whilst our employers provide some learning opportunities, by simply relying on these alone, we are restricting ourselves to the many amazing opportunities that are available to us, simply by the click of a computer button. One such learning opportunity in the challenge to improve patient care, is the understanding of human factors.

Human Factors

Within healthcare, the term human factors are synonymous with patient safety. In an attempt to make sense of the causes of harm, associated with human factors including both human failings, and organisational failings, the study of human factors has sought to identify problems and generate effective solutions to reduce the risks associated with maintaining patient safety.

According to the World Health Organization, human factors examines the correlation between humans and the processes and systems with which they interrelate, the aim of which is to improve ‘efficiency, productivity, creativity and job satisfaction’, whilst seeking to reduce the risk of errors. Investigating adverse incidents within the healthcare setting, often identifies a failure to apply these basic principles.

Contemporary organisations, particularly the aviation industry, have recognised human factors as being an important element of safety; this recognition now increasingly evident within the NHS. The Clinical Human Factors Group (CHFG) highlights the seriousness of the consequences of accidents and incidents borne out through errors within healthcare. Disturbingly statistical data highlighted by the CHFG makes for stark reading. But it doesn’t have to be this way. Improving safety through speaking up is both ethically and financially essential, and organisations should encourage employees to speak up and share their concerns, whilst demonstrating a supportive approach.

Developing a safety culture in which all staff, irrespective of roles and responsibilities feel empowered to raise concerns may also be a positive step in helping to reduce risk and is an essential element of any healthcare organisation seeking to promote patient safety.

Catherine Best

For many healthcare professionals their first introduction to human factors may be as a result of an incident in which a patient was harmed due to potential failings and again it shouldn’t be this way. By gaining insight into the complex world of human factors through the use of educational tools including the well-publicised videos ‘Just a routine operation’ and ‘Gina’s Story’, healthcare workers are able to learn about the devastating impact of these failings. Many more stories, such as these, no doubt exist.

The Swiss Cheese Model

One theory of how such incidents occur was proposed by James Reason in 1978 and is known as the Swiss Cheese Model. Through the use of this model we can better understand how errors occur; errors which have the potential to result in devastating consequences for both patients and their families, as well as our colleagues and the wider healthcare workforce.

A lack of effective training for example could be considered a contributory factor; another perhaps inadequate staffing levels. Agency staff can be a buffer, reducing the risk, or can be a mitigating factor, but buffers should no longer be relied upon exclusively  Other factors such as skill set and skill mix, attitude, beliefs and values, all play their part. The unwillingness to challenge senior staff and as nurses make our voice heard could also be argued is a significant factor, and is particularly evident in the Elaine Bromiley tragedy.

Developing a safety culture in which all staff, irrespective of roles and responsibilities feel empowered to raise concerns as emphasised by the work of the National Guardian may also be a positive step in helping to reduce risk and is an essential element of any healthcare organisation seeking to promote patient safety.

No caring health professional goes out to intentionally hurt someone; but it happens. Those involved in the cases mentioned did not intend their actions to lead to the tragic consequences.

From domestic staff to consultant and all roles in-between, we must all be aware of the importance of raising the alarm when we think something may be wrong, for ultimately this action may just save a patient’s life and potentially someone’s career.


A multitude of learning opportunities exist if you want to know much more about human factors. Let understanding about human factors be one of your goals when seeking to advance your knowledge and meet revalidation requirements.

Patient safety and human factors

Clinical Human Factors group

Medication Without Harm

eLearning for Healthcare – Freedom to Speak Up


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