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Crisis Management in Acute Care Settings: Human Factors, Team Psychology, and Patient Safety in a High Stakes Environment

Glavin, Ronnie J. MB, ChB, MPhil

Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare: February 2012 - Volume 7 - Issue 1 - p 61
doi: 10.1097/SIH.0b013e3182467c7f
Book Review

Scottish Clinical Simulation Centre Larbert, Scotland

The author declares no conflict of interest.

Some years ago, I attended a meeting of the Royal Aeronautical Society Human Factors Group. Presenters included James Reason, Ed Salas, and Mica Endsley (all of whom are referenced in this book), and during a question session, a training captain pleaded for a way in which the work that these scientists had built up could be made available and accessible to practitioners in the field. Many of us share that frustration; how can we gain access to the world of underlying theory in a way that will help us reflect on and modify our own practice? We need a map, especially those of us who have come into the world of human factors from the biomedical domain: a map that gives us a broad overview of the main themes and yet links them together in a coherent and comprehensible manner. The first edition of this book provided such a map.

The authors began with basic principles about error, complexity, and human behavior and then went on to look at factors operating at the level of the individual, the team, and the organization. These 4 sections encompassed 15 chapters. Each chapter began with a case study that put the subsequent material into a context, and the main themes from the world of human factors were then explored. The strengths were the synthesis of material from a large number of different workers explained in a logical and coherent fashion, with a consistency of style, good cross-referencing to material in other chapters, and a wealth of references.

A second edition is now available. What’s new, and how does it compare with its predecessor? In a nutshell, the book is longer (364 pages compared with 234 pages), has more references (668 compared with 378), has acquired a new coauthor (Robert Simon), and has had input from some other distinguished workers in the field of simulation-based health care (Walter Eppich for example). The layout is similar for the 4 basic sections and the number and overall structure and content of each of the chapters. The case studies, which deal with very acute clinical situations, worked well in the first edition and are unchanged.

The major changes are an expansion of some of the previous sections to improve comprehension—for example, the section on memory and learning and that on metacognition in chapter 4 have been substantially changed and are much the better for the revision. Other areas have been revised because of new material. Chapter 8 has a new section on vigilance that puts existing work in a better context. I also enjoyed the comparison between hours of sleep deprivation and equivalent alcohol consumption—very salutary material to bring to the debate about working long hours. The inclusion of the dual process ways of thinking, intuitive versus rational, has been added to chapter 10 and helps explain some underlying cognitive processes. I was disappointed not to see any references to the work of Pat Croskerry in relation to cognitive errors arising from the dual process model. Chapter 15 included much more on checklists and their roles within organizations, and there is also more on reporting systems. The standard of English of the first edition was excellent. The new coauthor, as a native English speaker, has corrected those few idiosyncrasies that can make translation such a challenge. However, I suspect that his real value has been his role in helping his fellow coauthors reflect on the content of the first edition and use that as a basis for revision. All chapters have undergone significant modification in addition to those that I have listed previously.

This book is an overview and is not a textbook. It is well laid out, with good use of diagrams (with some more added) and tables, and it handles the topics well. It is not a book to read from cover to cover because of the wealth of material contained within; rather, it is a book to read, reflect, reread, rereflect, and apply to one’s own practice. The concepts are well explained, but those who are new to human factors will need time to assimilate the material. The first edition was deceptive because of its relatively small size but large content. The small size was an advantage; the book was portable and could be easily carried from clinical workplace to simulation center and easily referred to when looking for some material that helped to explain to learners what had just happened and why. I was only able to review an electronic version of the second edition. The single-column-per-page layout is easier to read, but I am not sure what effect the additional 120 pages will have on the book’s portability.

Who should read this? If you want to understand why your learners have done what they have done and you want to help them with some countermeasures to reduce their chances of repeating their errors or mistakes, then this book will be of great help. If you are looking for an introduction into the theoretical underpinnings of human factors issues relating to health care, then this book will soon have you on more than nodding acquaintance with the A-list of human factors workers.

My request for the third edition is a short list of recommended reading at the end of each chapter to help readers build on the basic content. No simulation center should be without a copy, and even those very experienced in the field of simulation will benefit from reading this edition.

Ronnie J. Glavin, MB, ChB, MPhil

Scottish Clinical Simulation Centre, Larbert, Scotland

© 2012 Society for Simulation in Healthcare