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Human factors overview

Human factors have been highlighted before as causes of clinical errors in high-profile reports in obstetrics.

The 2014 MBRRACE-UK maternal report[i] highlighted ‘fixation error’ that must be avoided by being sure to “always consider other possible diagnoses in the event of failure to respond to treatment of the initial presumed cause of illness.” The Morecambe Bay report[ii] described “repeated instances of failure to communicate important clinical information about individual patients” as well as highlighting that “working relationships between staff groups were extremely poor”.


Generally, Each Baby Counts reviewers interpreted ‘human factors’ as being ‘human errors’ and the means to overcome them as ‘human factor training’. Whilst experience from the aviation industry and some early experience from obstetrics suggests that such training can be effective, connections to improved obstetric outcomes have yet to be made. Nontechnical skills training,[iii] human factors training and crew resource management all attempt to improve the abilities of healthcare providers to analyse and make sense of what is going on around them, to improve their situational awareness, team working and communication. Although not linked directly to improvements in outcomes, human factors training will raise awareness that human factors exist. Such training should standardise certain elements such as communication, understanding of personal bias, personality and team working.


The distribution of the human factors identified by Each Baby Counts reviewers as contributory to the outcome can be found in Table 8.


Table 8. Distribution of human factor critical contributory factors identified

Contributory factor

% of babies, N=556

Individual human factor issues


Situational awareness






Team issues


Intra- or interprofessional communication


Team leadership





Note: These contributory factors are not mutually exclusive; reviewers can indicate that there was more than one critical contributory factor in the care of each baby.


For this report, the focus was set on individual human factors rather than team issues in order to allow staff to take personal responsibility for their own development. All human factors involve human interaction in some way, so it has never been possible to completely separate individual and team factors. Team factors require multifactorial, complex interventions and will be the focus of a future report. The themes of situational awareness, stress and fatigue form the basis of the subsequent analysis.





[i] Knight M, Kenyon S, Brocklehurst P, Neilson J, Shakespeare J, Kurinczuk JJ (eds) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care - Lessons Learned to Inform Future Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–12. Oxford: National Perinatal Epidemiology Unit, University of Oxford; 2014.

[ii] Kirkup B. The Report of the Morecambe Bay Investigation. London: The Stationery Office; 2015.

[iii] Jackson KS, Hayes K, Hinshaw K. The relevance of non-technical skills in obstetrics and gynaecology. TOG 2013;15(4):269–74.