Hospital report highlights adverse events

For media interest…… 25/02/09

Hospital incidents report highlights adverse events but why does this happen?

The Series and Sentinel Events list published yesterday by the Ministry of Health’s Quality Improvement Committee, which reported 258 incidents, including 76 deaths is alarming, but it simply highlights the stressful environment of hospitals in this country.

This is the opinion of Werner Naef, a stress management specialist, who works with high-risk professions such as aviation, health, defence, occupational health and safety and high-speed rail in Europe, New Zealand and Australia. Mr Naef who is himself a former international airline pilot, and human factors trainer, says that whilst incidents inevitably do occur, it is not correct to just blame them on process or technology failure.

“Most of these incidents occur as a result of human error, and they occur when individuals are put under pressure or stress. In these situations, training sometimes goes out the window as a strange dominant logic takes over, and professional people who have a proven record of high quality performance, start displaying really odd behaviours and their decision making becomes impaired,” he said.

“We have seen this in aviation many times, and often this has resulted in a major air accident. When the analysis of the accident is completed, it is clear that the very well trained professional who has spent hours in the simulator going through the procedure, was still not able to handle the stressful situation in real life. Why does this occur? It is the human factor which comes into play, involving a mix of personality, psychometric state of mind, other stresses which the individual may be carrying, and even experiential stuff from his or her childhood which becomes evident.”

Mr Naef said that the experience gained in aviation and other high risk professions also applied to health sector and hospitals.

“Hospital operating theatres are a stressful environment. There are a number of reported incidents worldwide involving arguments, dysfunctional behaviour, even physical attack and stabbings which have occurred directly as a result of stress in this situation.

“Behind every one of the cases on the Series and Sentinel Events list, it is important to investigate what happened and what were the circumstances and events leading up to the incidents. I am sure many will relate to human error in crisis situations as a result of stress and distress.”

Mr Naef who is Wellington based, has been involved in stress management and human factors training for the past 30 years. He is a proponent of the process communication model, which was developed for NASA astronauts, and is now being introduced to various occupational fields in New Zealand and Australia.

“People management and managing their behaviours is becoming such a big aspect of the commercial world now that more and more companies are recognizing the importance of understanding their staff, knowing what makes them tick, and using the right techniques to motivate them to get the best results for the organisation.

“Human factors knowledge and training used to be a desirable extra. Now it is a mainstream requirement in recruitment, promotion, safety, and dealing with emergencies.”

The health industry has recognised this, and Mr Naef now works with a number of hospitals and medical groups in New Zealand and Australia. This has given him an insight into the medical professionals, and the relationships they have with each other, and how they network into a team in the operating theatre.

“If the team is functioning well, with good communication, co-operation and motivation, and a focus on the task in hand, then these incidents doe not occur. That happens in the majority of cases, as the 900,000 patients who were successfully treated and discharged across the country last year can attest. But the 258 cases of incident were all preventable as Dr Snedden from the Auckland DHB said, so that is where the focus must fall,” Mr Naef said.

“Human factors training is all about preparing people for stressful situations, and helping managers to identify stress in staff members at an early stage, decoding their behaviour, intervening with appropriate support, and helping people to make the U-turn back into positive behaviour.”

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