Human Error and Error Wisdom

Human Error and
Error Wisdom
Content from National Patient Safety Agency material

http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/
Human error
“We all make errors irrespective of how much

training and experience we possess or how
motivated we are to do it right”.
Reducing error and influencing behaviour - HSG48

Aoccdrnig to rscheearch at Cmabrigde
Uinervtisy, it deosn't mttaer in waht oredr the
ltteers in a wrod are, the olny iprmoetnt tihng is
taht the frist and lsat ltteer are in the rghit pclae.
The rset can be a total mses and you can sitll raed
it fialry eailsy.
Tihs is bcuseae the huamn mnid deos not raed

ervey lteter by istlef, but the wrod as a wlohe.

?

The Perfection Myth
- if we try hard enough we
will not make any errors
The Punishment Myth

- if we punish people
when they make errors
they will make fewer of
them

Getting the balance right
Both extremes
have their
pitfalls

How do accidents happen?
Organisation + process deficiencies - (SDPs)
Prior/unsafe conditions - Contributory factors
Unsafe acts - (CDPs) / (SRK errors)
Failed defences
Patient
Safety
Incident

Rasmussen’s Skill, Rule and Knowledge (SRK) model
Automatic, familiar & well

Conscious Skill practiced routines
Thought
Learning rules and
Rule rehearsing routines
Novel task
Knowledge

ERROR TYPES
– based on the work of Reason, adapted by NPSA
Basic error types Routine

Reasoned
Reckless & Malicious
Violations
Intended
actions Rule & Knowledge
Based errors
Unsafe
Unsafe
acts Mistakes Skill based errors
acts Memory failures
Unintended Lapses
actions
Skill based errors
Slips Attentional failures
Def: Human Factors
The study of how humans behave physically
and psychologically in relation to particular
environments, people, or procedures.
www.npsa.nhs.uk/rca

Lessons from Human Factors Research
• Errors are common and predictable
• The causes of errors are known
• Errors are by-products of useful cognitive functions
• Errors can be prevented by designing tasks and processes

to minimise dependency on weak cognitive functions

Examples of Other Human Factors
Fatigue; Sleep deprivation
Inadequate nutrition, hydration
Overload
Training and experience
Professional courtesy
Team dynamics (isolated, divided, elite)
Leadership (weak, charismatic)
Example outcomes :
Perceptual and contextual problems ……….
Perception

Contextual clues leading to error
(Bum steers)
What tree grows from an acorn? Oak

What do you call a funny story? Joke
What sound does a frog make? Croak
What’s another word for a cape? Cloak
What do you call the white of an egg?
Humans as Heroes
Error is normal
• Humans are bad at routine but good at
compensation/recovery
• Human coping resources are good

• Humans have capacity for realistic optimism
• Good compensators have good outcomes
Reason, PS Congress 08
Error Types
Intended actions
Routine violations - regular short-cuts in tasks made for convenience. They are accepted by the clinical
team, and sometimes by management, normally because the procedure is badly designed.
Reasoned violations - occasional changes in procedure for good reason and with good intent. It may be an
emergency or unusual situation. The change should be discussed beforehand wherever possible and always
documented afterwards.
Reckless violations - unacceptable changes in procedure. Harm is likely but not intended. There is an active
lack of care.
Malicious violations - deliberate acts that are intended to cause harm or damage. They are unusual but the
outcome is likely to be very serious.
Rule based mistakes - made by people undertaking tasks with some knowledge of the rules and with good
intent, but they choose the wrong solution for the problem.
Knowledge based mistakes - made by people undertaking new tasks with good intent but their limited
knowledge results in a mistake. They don’t know that they don’t know.
Unintended actions
Lapses - errors made by experienced people undertaking familiar tasks with very little conscious thought.
They forget something routine when they are not concentrating on the task or when they are interrupted.
Slips - errors made by experienced people undertaking any task. There is a slip in the action [such as dropping
an instrument] which could happen to anyone, however experienced.
Either we manage human error...
... or human error will manage us
Professor James Reason

Key Points - Human Error
• The reasons things go wrong are fairly predictable
• Humans are generally bad at routine and good at

compensation / recovery
• We need to use this wisdom to identify the true causes

of incidents ... and the most effective solutions

Human Error and Error Wisdom

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Human Error and

Content from National Patient Safety Agency material

“We all make errors irrespective of how much

Reducing error and influencing behaviour - HSG48

Content from National Patient Safety Agency material

Tihs is bcuseae the huamn mnid deos not raed

Content from National Patient Safety Agency material

Content from National Patient Safety Agency material

The Punishment Myth

Content from National Patient Safety Agency material

Content from National Patient Safety Agency material

Organisation + process deficiencies - (SDPs)

Prior/unsafe conditions - Contributory factors

Unsafe acts - (CDPs) / (SRK errors)

Content from National Patient Safety Agency material

Automatic, familiar & well

Content from National Patient Safety Agency material

Basic error types Routine

Content from National Patient Safety Agency material

• Errors are common and predictable

• The causes of errors are known

• Errors are by-products of useful cognitive functions

• Errors can be prevented by designing tasks and processes

Content from National Patient Safety Agency material

Content from National Patient Safety Agency material

What tree grows from an acorn? Oak

• Human coping resources are good

... or human error will manage us

Professor James Reason

Content from National Patient Safety Agency material

• The reasons things go wrong are fairly predictable

• Humans are generally bad at routine and good at

• We need to use this wisdom to identify the true causes

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