A human factors approach is user centred. It improves safety by designing work systems that support people to do the right thing and reduce the risk of serious error. It considers what happens at individual, team and system levels and is used in safety-critical industries such as aviation and rail, as well as in health and social care.

Human factors draw on psychology, engineering, design and physiology. In health and social care, it focuses on improving the design of workflows, environments and processes to support safer care, reduce errors and improve outcomes.

In health and social care, you work with others every day, including the people you care for, your team and other professionals. Most interactions go well, but risks can arise from:

• communication breakdowns, including verbal, non-verbal and written errors
• hierarchical relationships, which can make it harder to speak up
• loss of situational awareness.

These can increase the risk of errors and harm.

Key aspects of human factors include:

• Cognitive factors: How we think and process information. Situational awareness, decision-making, attention, memory, and workload management.
• Personal factors: How our bodies work. Human variability and capability, stress and fatigue management, and interaction with physical environments.
• Organisational, Social and Environmental factors: How we work together and our environment. Work culture, communication, team dynamics, leadership, and environmental design.
• Human-technology interaction: How we use technology. Usability of tools, interfaces, and automation reliability.

(Applied Psychology and Human Factors Group)

An understanding of human factors recognises and places value on the impact workplace culture has on achieving desired outcomes. “Implementing, enhancing and maintaining patient safety within health care organisations often begins with fostering a robust safety culture framework.” (WHO, 2024)

Creating a safe and efficient health and social care environment requires a mix of smart design, teamwork and well-structured processes. Here are four key strategies that can improve interactions among staff, equipment and workflows:

Improve communication and teamwork

• Use structured formats for communication and passing on information (for example, SBAR: Situation, Background, Assessment, Recommendation and the Surgical Safety Checklist).
• Create a plan of action for care and emergency conditions and ensure the whole team know the escalation processes.
• Undertake multiprofessional team training and team debriefs to improve teamwork and shared learning - simulation offers the chance to develop the necessary skills and practice for emergencies.
• Encourage speaking up—foster a culture where all staff feel comfortable raising safety concerns without fear of blame.

Design workspaces for safety and efficiency

• Have a clear layout—ensure equipment, emergency exits and supplies are easily accessible and well-maintained.
• Reduce clutter and noise—reduce unnecessary alarms and background noise that can lead to stress and miscommunication.
• Use good lighting to prevent errors and design workstations to reduce physical strain.

Strengthen safety procedures and reporting systems

• Encourage staff to report near-misses and errors to improve systems, taking a fair and supportive approach rather than a punitive style to reporting.
• Investigate mistakes to find system issues rather than blaming individuals.
• Conduct and engage in routine audits to identify potential hazards and potential areas for improvement before they cause harm.

Proactively address and manage staff wellbeing

• Work to ensure adequate staffing levels on each shift to reduce stress and fatigue. Report and document when this is not achievable.
• Rest, Rehydrate and Refuel—ensure the nursing workforce take their rest breaks. A missed break is a patient safety issue.
• Foster self-care and seek support such as counselling and peer support, as needed, to address issues early.

By focusing on clear communication, smart workspace design, easy-to-use technology, staff well-being, and a strong safety culture, health and social care environments can be much safer and more effective.

Watch the video ‘Just a routine operation - video from Martin Bromiley, pilot (2012)’. This is the story of Mrs Elaine Bromiley, a fit and healthy 37-year-old mother of two, who attended the hospital for an elective routine nasal procedure.

The video documents how unexpected complications during the administration of anaesthesia led to Elaine sustaining severe and irreversible brain damage. Her story became a situation of ‘can’t intubate, can’t ventilate’, a recognised anaesthetic emergency, for which guidelines exist, after prolonged attempts to secure her airway failed. Sadly, Elaine died 13 days later.

After watching the video, we encourage you to take a moment to reflect on these questions and think about the significance of Elaine’s story and its impact on her and her family.

Understanding the story

• What were the key events that led to Elaine Bromiley’s tragic outcome?
• How did communication—or the lack of it—impact the outcome in this case?
• What roles did hierarchy and team dynamics play in the situation?

Human factors and decision-making

• What human factors contributed to the failure in this scenario?
• How might cognitive overload or stress have influenced the clinical team’s decisions?
• What ergonomic or system design issues can you identify in the operating room environment?

Teamwork and communication

• How could better communication have changed the outcome?
• What tools or strategies could have supported more effective teamwork in this case?

Systems thinking and safety culture

• What does this story reveal about the importance of a safety culture in health care?
• How can health care systems be designed to better support clinicians under pressure?
• What changes would you propose to prevent a similar event from happening again?

Personal reflection

• How did this story make you feel, and why?
• What lessons will you take into your own practice?
• Have you ever witnessed or experienced a situation where human factors played a critical role? What did you learn from it?

It is important to note that all members of the team involved in Elaine’s story were experienced staff considered diligent and respected. An independent report by Michael Harmer, MD FRCA, highlights some of the following factors:

• Loss of situational awareness: During the emergency, the consultants became narrowly focused on repeated attempts to secure the airway, losing sight of the overall situation, including the passage of time and clear signs of deterioration such as falling oxygen saturations and declining heart rate. Both indicated inadequate oxygen delivery to the heart.
• Perception and cognition: The recommended actions for a ‘can’t intubate, can’t ventilate’ scenario were not followed. Under pressure, alternative options to address the worsening situation were not adequately considered, reflecting cognitive overload and fixation.
• Teamwork: No clear leader was identified during the emergency. Effective crisis management requires someone to oversee the whole situation, coordinate actions and plan. Although consultants were offering help, the absence of designated leadership led to breakdowns in decision‑making and communication.
• Culture and hierarchy: Nurses recognised the seriousness of the event by bringing emergency equipment and alerting the ICU but felt unable to speak up when their concerns were not acted upon. Hierarchical pressures hindered assertiveness, preventing staff from challenging decisions despite the escalating risk.

Learning points

• Maintain situational awareness: Avoid becoming fixated on one task; keep sight of the whole clinical picture, including the passage of time and signs of deterioration.
• Follow emergency procedures: In high‑pressure situations, use established guidance and escalation processes and actively consider alternative actions when the situation worsens.
• Ensure clear leadership: Every emergency needs an identified leader to coordinate actions, support decision‑making and maintain a shared understanding of the plan.
• Strengthen communication and teamwork: Unclear roles and a lack of leadership can undermine decision‑making and delay critical interventions.
• Address cultural and hierarchical barriers: Staff must feel safe and able to speak up when they have concerns; a culture of psychological safety is essential to prevent harm.
• Act on concerns promptly: When team members raise concerns—verbally or through actions such as bringing emergency equipment—these cues must be acknowledged and acted upon.

In The Story of Elaine Bromiley by the Clinical Human Factors Group, the charity working to make health care safe, Martin Bromiley (Elaine’s husband) outlines the role of human factors and ergonomics in improving patient safety.