Appendix F. Human factors
The Committee of Ministers, under the terms of Article 15.b of the Statute of the Council of Europe,
Considering that the aim of the Council of Europe is to achieve a greater unity between its members and that this aim may be pursued in particular by the adoption of common rules in the health field;
Considering that access to safe health care is the basic right of every citizen in all member states;
Recognising that although error is inherent in all fields of human activity, it is however possible to learn from mistakes and to prevent their reoccurrence and that health-care providers and organisations that have achieved a high level of safety have the capacity to acknowledge errors and learn from them;
Considering that patients should participate in decisions about their health care, and recognising that those working in health-care systems should provide them with adequate and clear information about potential risks and their consequences, in order to obtain their informed consent to treatment;
Recalling that Article 2 of the Council of Europe’s Convention on Human Rights and Biomedicine (ETS No. 164) establishes the primacy of the human being over the sole interest of society or science, and recalling its Article 3 on the equitable access to health care of appropriate quality;
Considering that the methodology for the development and implementation of patient-safety policies crosses national boundaries and that their evaluation requires substantial resources and expertise and should be shared;
Recalling its Recommendations Nos. R (97) 5 on the protection of medical data, R (97) 17 on the development and implementation of quality improvement systems (QIS) in health care, and R (2000) 5 on the development of structures for citizen and patient participation in the decision-making process affecting health care, and its Resolution ResAP(2001)2 concerning the pharmacist’s role in the framework of health security, which explicitly suggests working in partnership with other health professionals;
Noting the relevance of the World Health Organisation (WHO) “Health for All” targets for the European Region (target 2) and of its policy documents on improving health and quality of life and having regard to its Health Assembly Resolution 55.18 (2002) on “Quality of care: patient safety”, which recognises the need to promote patient safety as a fundamental principle of all health systems;
Considering that patient safety is the underpinning philosophy of quality improvement and that all possible measures should therefore be taken to organise and promote patient-safety education and quality of health-care education;
Considering that the same principles of patient safety apply equally to primary, secondary and tertiary care and to all health professions as well as to health promotion, prevention, diagnosis, treatment, rehabilitation, and other aspects of health care;
Recognising the need to promote open co-ordination of national and international regulations concerning research on patient safety,
Human factors
See Appendix F (pdf-file) of Recommendation Rec(2006)7 of the Council of Europe
Note: text markers added to increase readability (not applied in the original).
1. In order to reduce and prevent patient-safety incidents, health professionals must understand their own behaviour patterns, their decision-making process and their ability to cope with challenging situations in daily activities.
2. Health professionals should be given the opportunity to learn how to handle guilt and be supported to avoid becoming “the second victim” of the safety incident.
3. Support from the organisation to the health professionals is crucial to make disclosure of the incident possible and to enable continuation of work in health care, where risks will always exist and adverse events happen.
4. Decision-making supports such as reference works and reminders cannot replace sound human and clinical reasoning.
5. Sharing decision making with patients should be learned and applied in practice when appropriate.
6. All measures that increase patients’ compliance with their treatment should be implemented in order to avoid both poor outcomes and safety incidents.
7. Education and training curricula for all health professions should include basic knowledge on: the principles of clinical decision making, risk awareness, risk communication, risk prevention, individual and collective attitudes and behaviour in the case of adverse events (medical, legal, financial and ethical aspects).
8. Continuous education should contribute towards building a safety culture in health care by changing attitudes, from an illusion of infallibility to acceptance of human error and to the ability to learn from mistakes.
9. Interdisciplinary co-operation, a non-hierarchical structure and open communication in health-care organisations are necessary for building a safety culture. In some specialities systematic training in team work is indispensable.
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