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

Summary

“…active failures are like mosquitoes. They can be swatted one by one, but they still keep coming. The best remedies are to create more effective defenses and to drain the swamps in which they breed.”

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

There has been much progress in our understanding of error, but potential errors are an inevitable part of our reality. By expanding our understanding of the anatomy of errors we are better positioned to create more effective defenses.


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Patient safety module series used with permission from Duke University
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