Today another lived experience was shared. It was that of a widowed husband, this time from the UK, who shared the experience of his wife, undergoing what was a routine surgery but ended up not making it to surgery and having a fatal consequence as a net result of an adverse event and subsequent accrual of system failures, particularly those of a human factor nature. This brings to the light the many human factors that we continually witness in practice, which may be harmful especially when aligned in particular contexts, notably in situations that are unfamiliar or deviate from the norm. One of the things I particularly reflected on is how we as humans are fallible to task focus and makes us become situationally unaware. It is something we need to keep in mind when retrospectively analysing incidents. Even I have to admit that I have been unaware on occasion.… Continue reading →