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  • Writer's pictureLilian Chiwera

Human factors, change management & surgical site infection prevention

To err is humanis a quote you often hear at patient safety conferences, when reviewing incidences that involve near misses or when undertaking Root Cause Analyses (RCAs). My go to phrase when I identify increasing trends in surgical site infection (SSI) tends to be ‘increased vigilance recommended’. And yet Donaldson suggests that individuals cannot remain vigilant for a long time and thus an overemphasis or reliance on vigilance may not always be the best option. In fact it may be better to consider automating processes whenever possible or use easy to follow checklists. Considering that in today’s complex healthcare systems, there are many variables which influence patient outcomes such as:

a)the number of actors involved

b) the explosion in available processes, procedures and technologies

c) the throughput of patients

d) the ratio of nurses to patients

e) the dependency of patients

f) the layout of clinical areas’; there is a need to review, address or consider all these variables when designing efficient systems that minimise patient harm and promote patient safety. All the above variables are applicable to surgical settings and must therefore be reviewed as part of surgical site infection surveillance and prevention and other infection prevention work.

System designs

Another quote you often come across in ergonomics is ‘every system is perfectly designed to deliver the results it gets’; meaning that systems may harbour intended and unintended consequences depending on how they were designed. Given that humans interact with systems, design of these systems must be carefully planned and executed to minimise errors and promote safety. With due consideration for all eventualities, a good design ‘makes it easy for ‘humans’ or people to do the right things’. It is however acknowledged that ‘human error is not absolutely preventable and systems need to be designed that are resilient when human errors occur’. Be that as it may, people must always endeavour to ‘do it right the first time’ - a common concept that is promoted heavily in commercial industry settings with the aim of increasing productivity and optimising profits and the quality of finished products. In hierarchical organisations, where frontline systems are designed from the top without adequate consultation with end users, frontline staff can be presented with a ‘perfectly designed system on paper’. This type of system may not yield intended results particularly when key practical aspects are not considered at design stages. It is therefore crucial, that systems are designed with frontline input as much as is practically possible, to minimise error risk; whilst also engaging all the other key stakeholders. In project design, they talk of piloting small changes first to ensure suitability for large scale roll out is carefully scrutinised.

So how does this apply to SSI prevention?

In my previous blog, I discussed the concept of SSI prevention care bundles and highlighted the importance of achieving good compliance to achieve the best outcomes for surgical patients. If a system or quality improvement strategy is not perfectly embedded within organisational governance structures, to facilitate consistent implementation of SSI prevention measures for example, then that system is likely to fail to yield favourable outcomes. Patients may miss out on some evidence based SSI prevention interventions or elements and consequently develop SSIs.

Change management

One would hope to get perfect results from perfectly designed systems; however this is not always the case as other human and environmental factors may distort these perfect designs. COVID-19 is an example of a crisis that would have impacted a lot of perfectly designed systems, leading to unintended consequences. Systems without inbuilt resilience within them would have fallen apart and yet for many, various changes to systems, coupled with adaptations to human behaviours became necessary. Of course, it’s always a huge undertaking to change human beings, therefore in general change management can be considered to be a difficult task. However, as with COVID-19 for example, change can often be the only option particularly where an alteration of human behaviours is necessary to sustain or save lives. Similarly, in other infection prevention and control aspects or surgical site infection prevention, change can be mandated after never events or avoidable harm is highlighted. Furthermore, changes may become necessary when new evidence becomes available. It takes committed change agents with a passion and determination to achieve positive results to convert and encourage others to change their inherent practices when a need arises. These individuals are often referred to as ‘Movers and Shakers’ who can facilitate changes in large organisations. In the era of evolving evidence based practice, various change cycles may become necessary to enable new evidence based practices to be assimilated in people’s mind-sets before they become their ‘new normal’. Sadly, as we have seen during the COVID-19 pandemic, staff may have to unlearn a ‘new normal’ soon after getting used to it when new evidence becomes available. This can lead to frustration, therefore the necessary support systems must be made available for staff to access. Thankfully, quick turnovers in evidence based SSI prevention recommendations have not been common practice to date; albeit continuous quality improvement systems are always available to ensure subtle changes in human behaviours are picked up early.

Humans must be as adaptable as they can possibly be for them to consistently yield positive results, considering that change is inevitable is most scenarios. At the same time we know that changing human behaviours is not always easy, therefore persistence, passion, patience and kindness must be integral to all efforts invested in change management. It is almost unavoidable that mistakes may happen even in a perfectly designed system as already highlighted above, a non-blame culture must be adopted when reviewing incidences and any learning that comes with it. In a thought paper by Storr, Wigglesworth & Kilpatrick, there is an argument for embedding human factors principles within infection prevention and control (including surgical site infection prevention) capacity and capability. The authors point out what we already know about infection risks and outcomes for patients. ‘The more vulnerable the person, the greater the risk to them from what we do – no matter how necessary. Infection acquired as a result of healthcare is an adverse outcome, often a culmination of a series of lapses, errors and omissions arising in that complicated healthcare system. Its consequences can be devastating…’ It is therefore necessary for us to remember that when we undertake various ‘necessary’ surgical procedures for our patients, we also rigorously address our systems to minimise the risk of lapses or omissions as much as possible in order to optimise outcomes for these patients. This is particularly important when a care bundle approach is adopted as part of the patients’ surgical or other care pathways as highlighted in my previous blog.


In as much as ‘to err is human’, we must also try as hard as we can to make it easy for people to do the right things and design systems that support human efforts; knowing that systems are perfectly designed to give the results that they get. Everyone must be amenable to change when it becomes necessary for patients’ benefit. Lastly, I highlight Reason’s ‘Swiss cheese’ model of error causation related to infection prevention and control that was presented by Storr and colleagues for you to consider:

Taken from a thought paper for The Health Foundation on Integrating human factors with infection prevention and control by Julie Storr, Dr Neil Wigglesworth, Claire Kilpatrick

… and leave you with these interesting human factors insights and perceptions from Anderson et al which they highlight for when staff view other clinical tasks as separate from infection prevention and control:

  • ‘the inevitable delayed feedback between omission and consequence

  • the lack of connection in the mind of the healthcare worker with a positive result

  • time pressure and high cognitive workload

  • the lack of consistent, inbuilt infection control cues

  • a historic failure to take sufficient account of design'.

 How can you apply the above to Surgical Site Infection Surveillance and Prevention?

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