Patient Safety Tip of the Week

May 31, 2011

Book Review:

Human Factors and Team Psychology in a High Stakes Environment



Per our tradition, we have usually reviewed a patient safety book over the holiday. We had hoped to review Sidney Dekker’s new book but Amazon had not yet released it. So you’ll have to wait for the July 4 holiday for that review. Instead we read “Human Factors and Team Psychology in a High Stakes Environment” (St. Pierre et al 2008). We weren’t disappointed. This is a good book to read regardless of how far along you are into human factors and patient safety. Quite frankly, for those of you who are new to the concepts of human factors engineering in healthcare this is actually a great book to start with! It covers the key human factors concepts and does so in a readable and understandable fashion (those of you who have struggled through some of the original human factors literature will appreciate the simplicity of language in this book!).


Each chapter begins with a brief clinical vignette that serves as a trigger for several discussion points in that chapter. You know we like that technique because everything is much easier to remember when it can be tied to a “story” of some sort.


The first chapter begins with a discussion about how we use mental models to help us plan and implement actions. But it also notes many of the things we do that can lead to errors. For example, we frequently adjust our preferred mental model instead of challenging our current point of view  (i.e. we often look for confirming information and ignore disconfirming information). And we have a tendency to “defend our feeling of competence”. They also have a brief discussion here about the value of teams (eg. increasing cognitive resources, having more to shoulder the load, etc.) but also note that teams can, for a variety of reasons, sometimes degrade the performance of individual team members. (They delve into teamwork in detail in later chapters). They note that technical proficiency is not enough and that non-technical skills, such as interpersonal skills (communication, leadership, teamwork) and cognitive skills (situational awareness, planning, decision making, task management, etc.) are equally important.


The second chapter stresses the dynamics of critical situations and the need to keep your mental model up-to-date and stress flexibility as being key to dealing with such. They note we often miss subtle situational clues but can also be overwhelmed by too much information. Here they do also get into the cognitive psychology concepts of skills, rules, and knowledge. The third chapter discusses examples of errors related to execution failure and planning failure and the concepts of slips, lapses, mistakes, bad rules, misinterpretation of good rules, and nonapplication of good rules. They also discuss violations vs. errors and how latent errors combine with active errors to produce critical sitiuations. They also begin to talk about teamwork errors.


The fourth chapter begins with a physician responding to an incident in which both a police officer and a perpetrator are shot. The physician tends first to the officer, who has the less severe injuries, leaving the more seriously injured patient unattended for a long time period. That leads to a discussion of how emotions and feelings and attitudes may drive some of our actions. Chapter 5 focuses on how our perception affects our mental models and discusses how we need to take second looks and consider how our emotions may be affecting our perception. Chapter 6 discusses many cognitive psychology concepts like schemata and scripts and how our brain tends to use the most cognitively economic resources, which may not be the most appropriate in many situations. Concepts such as “blindness to the obvious”, fixation errors, ambiguity aversion, and other biases are discussed. This chapter has some useful tips on “wiping the slate clean”, critically evaluating your first hypothesis and generating alternative hypotheses.


Chapter 7 is an excellent discussion on goals, which serve as beacons for actions. They note that goals should be positive (not negative or ambiguous), specific, structured and prioritized but also flexible. They should be checked for conflicts and contradictions. Importantly, they stress we need to be aware of “non-factual” goals. The latter are goals such as control, status, power, demonstration of competence, etc. that often unconsciously interfere with the tasks at hand. It also has a good discussion of planning.


Chapter 8 gets into the concepts of attention, vigilance, concentration, and situational awareness and discusses how fatigue impairs multiple functions. Chapter 9 is all about how stress (both acute and chronic) can impair judgement, lead to cognitive tunnel vision and other maladaptive behaviors. It also develops the concept of team stress.


Chapter 10 discusses the steps taken in good strategies and the potential use of decision aids (such as the DECIDE aid used in firefighting or the FOR-DEC used in aviation). They highlight the importance of reviewing effects of a strategy to detect errors early and asking for feedback from all team members to assess both effectiveness and potential for errors.


Chapter 11 begins to focus on the role of teams in detail. It talks about the positive attributes of good team players (eg. good listeners, be self-critical, solve conflicts constructively, etc.) and has a good discussion on how teamwork “grows”. They stress how good team members cross monitor each other, both for errors and to ensure that workload is not unbalanced. It notes the importance of team training, feedback, and open communication but also goes into why some teams fail. It notes some character traits of “bad” team members and why communication sometimes fails. It gets into shared misconceptions and the problems sometimes encountered with “group think”, majority vote, and  the illusion of unanimity. This chapter has some excellent practical tips for teams (rehearsing skills daily, clarifying roles, stating opinions clearly, speaking rather than implying, cross monitoring teammates, etc.


Chapter 12 is all about communication. It is very good about aspects of communication aside from words. It has an excellent discussion about how tone, pitch and pacing of speech can significantly impact communication and how nonverbal communication (gestures, posture, facial expression, eye contact, etc.) are critical parts of communication. They provide some great examples of how the same message can be helpful or detrimental, depending on how that message is delivered. It highlights features of good and bad listening and how some interpersonal conflicts may lead to behaviors that impair good communication..


The remaining chapters discuss leadership, organizational issues, and many patient safety and quality improvement concepts.



Overall, this is a good book for you to get an understanding of many of the basic elements of human factors and it has excellent discussions about teams, communication, and leadership. This is a very worthwhile read!



Note: There is a new hardcover version of this work that is to be released soon (due out on July 29, 2011). You may wish to wait for its release, though if you like reading the e-reader version (Kindle in this case) you can read the original version now.





St. Pierre M, Hofinger G, Buerschaper C. Human Factors and Team Psychology in a High Stakes Environment. 2008 Springer Verlag, Berlin Heidelberg (Kindle edition)














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