Overview
Definitions of Error
Basic Tenets of Human Error
Human Factors Engineering
Human Performance
Vocabulary
Types of Errors
Systems to Reduce Errors
Stroop Test
Swiss Cheese Model
Toxic Cascades
Lessons from Other Industries
Basic Safety Principles
Summary

Systems to Reduce Errors

“We cannot change the human condition, but we can change the conditions under which humans work.”

Reason J. BMJ 2000; 320:768-770.

Because humans are fallible, we must rely upon systems and back-ups to prevent or detect errors before they can cause harm. Unfortunately, our systems are not always designed well to achieve this. System and design factors that can lead to bad outcomes include:
Complexity:
  • Too many steps
  • Too many people (communication issues)
Workload:
  • Too heavy or too light (performance is best when workload is moderate)
  • Too much reliance on human vigilance/monitoring
Poor design:
  • Focus on functionality, while ignoring the real-life user
The work environment in which a system functions also impacts the failure rate.
Interruptions and distractions:
  • Frequently associated with errors – up to 50% in aviation studies
  • Yet extremely common in healthcare – ED physicians experience up to 10 interruptions per hour (Chisolm et al. Acad Emerg Med 2000; 7(11):1239-43.)
Culture:
  • Authority structure impeding communication
  • No assignment of responsibility
  • See module: Culture of Safety for more details
 
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Patient safety module series used with permission from Duke University
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