Human factors inspection in the healthcare industry


Our healthcare client is responsible for the collection, manufacturing, testing, storage and issue of approximately two million healthcare components per annum, to 300 hospital customers.

“Potential errors in healthcare manufacturing processes can lead to patient harm/fatality, as well as the loss of audit trail. Organisations must strive continuously to reduce errors across all their processes and sites.”
Tania Heasman, former Managing Director, System Concepts (and co-author of the HSE publication Reducing Error and Influencing Behaviour HSG48.)


The client was seeking to reduce its already low level of human error, to fewer than four errors per million. Our role was to use in-depth specialist evaluation techniques, to build on a number of error-reduction initiatives that the client had previously undertaken.

We were then to assist in the design and facilitation of workshops to engage and educate staff, integrating human factors error reduction techniques into overall corporate strategy.

What we did

We had previously run a series of projects to examine the client’s manufacturing processes, reduce the level of inspection and other errors, and investigate how to integrate human factors, as part of its continuous improvement process. This included human error analysis, ergonomics and behavioural safety considerations.

This earlier phase of work involved visiting large manufacturing sites, where we conducted confidential staff interviews, undertook task analysis of manufacturing processes, and observed repetitive processes. As a result of this, we delivered very wide-ranging, testable recommendations.

Management workshops
Following the success of the initial project, we were commissioned to run workshops for senior managers. These included analysing some additional areas of the client’s technical/manufacturing processes, where it was considered that a human factors approach would be beneficial.

Rapid Improvement Event
We helped facilitate a two-day Rapid Improvement Event, staged for a part of the client organisation involved in highly complex processes, with raised scope for human error.

The event was attended by over 30 scientists, biologists, engineers, quality managers and health and safety representatives. Through presentations and practical work, we raised awareness of human factors, then helped the organisation to examine its processes using a human factors approach. Testable suggestions for improvement were developed, and a prioritised action plan was drawn up.

Strategy workshop
A second workshop was led and facilitated by System Concepts, to take a strategic look at the organisation’s human factors and behavioural safety, and how best to integrate new interventions. This was attended by senior strategic and operational managers, and supported by the project steering team.

Our consultants’ preparation for this workshop included holding project planning meetings with senior members of the operations teams. We also engaged with frontline employees responsible for operations identified as potentially risky and error prone: this informed the materials we used at the workshop.


The Rapid Improvement event enabled client teams to examine key processes, identify potential failure points, and develop solutions. These included technological solutions, workplace and workstation layout, administrative controls, design-out-at-source issues, equipment selection and staff training/awareness.

The strategic workshops gave our client’s senior managers an understanding of the scope and range of human factors interventions. These spanned reducing errors, physical ergonomics and manual handling, and their potential value in improving safety and quality. We made sure that they bought-in to the message, by presenting rigorously constructed evidence of real-life operational examples.

As a result of this work, our client is well positioned to reduce errors, improve productivity, and enhance staff safety and comfort.


More like this