Examples Of Human Error
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Island accident), aviation (see pilot error), space exploration (e.g., the Space Shuttle Challenger Disaster and Space Shuttle Columbia disaster), and medicine (see medical error). Prevention of human slips lapses and mistakes error is generally seen as a major contributor to reliability and safety
Human Error Accidents
of (complex) systems. Contents 1 Definition 2 Performance 3 Categories 4 Sources 5 Controversies 6 See also 7 References human error definition Definition[edit] Human error means that something has been done that was "not intended by the actor; not desired by a set of rules or an external observer; or that led the task https://www.nopsema.gov.au/resources/human-factors/human-error/ or system outside its acceptable limits".[1] In short, it is a deviation from intention, expectation or desirability.[1] Logically, human actions can fail to achieve their goal in two different ways: the actions can go as planned, but the plan can be inadequate (leading to mistakes); or, the plan can be satisfactory, but the performance can be deficient (leading to slips and lapses).[2][3] However, a https://en.wikipedia.org/wiki/Human_error mere failure is not an error if there had been no plan to accomplish something in particular.[1] Performance[edit] Human error and performance are two sides of the same coin: "human error" mechanisms are the same as "human performance" mechanisms; performance later categorized as 'error' is done so in hindsight:[4][5] therefore actions later termed "human error" are actually part of the ordinary spectrum of human behaviour. The study of absent-mindedness in everyday life provides ample documentation and categorization of such aspects of behavior. While human error is firmly entrenched in the classical approaches to accident investigation and risk assessment, it has no role in newer approaches such as resilience engineering.[6] Categories[edit] There are many ways to categorize human error.[7][8] exogenous versus endogenous (i.e., originating outside versus inside the individual)[9] situation assessment versus response planning[10] and related distinctions in errors in problem detection (also see signal detection theory) errors in problem diagnosis (also see problem solving) errors in action planning and execution[11] (for example: slips or errors of execution versus mistakes or errors of intention[12][13]) By level of analysis; for example, perceptual (e.g., optical illusions) versus cognitive versus communication versus organiza
Principles Summary Types of Errors Reason classified errors based on Rasmussen’s 3 http://patientsafetyed.duhs.duke.edu/module_e/types_errors.html levels of performance Skill-based errors – slips and lapses – http://patientsafetyed.duhs.duke.edu/module_e/definitions.html when the action made is not what was intended Rule-based mistakes – actions that match intentions but do not achieve their intended outcome due to incorrect application of a rule or inadequacy of the plan. Knowledge-based mistakes human error – actions which are intended but do not achieve the intended outcome due to knowledge deficits. Examples: Click on each of the images below to see examples. Also used occasionally is the term “strong but wrong.” This refers to erroneous behavior that is in keeping with examples of human past practice rather than current circumstances. This type of error is very difficult to overcome, as people who have positive experience with a particular behavior can be very confident in their actions under slightly different circumstances, even when those actions are wrong. Check your understanding: Classify each of the following errors by reason’s levels. Skill-based Rule-based Knowledge-based Taking the turn to go to work on your day off, when you intended to go elsewhere A gardener plants an azalea shrub (needs acid soil) at his seaside cottage (unsuitable saltwater condition) An apprentice furniture designer cuts the wood panel to the wrong width by failing to account for the thickness of the saw blade Questions about this website, please email: CFM_Webmaster@mc.duke.edu © 2016 Department of Community and Family Medicine, Duke University School of Medicine. All Rights Reserved.
Principles Summary Definitions of Error The dictionary gives many definitions of error. These include: Something incorrectly done through ignorance A transgression of law or duty; a mistake in conduct; a moral fault Dr. James Reason, a Professor of Psychology who has published extensively on the nature of human error, describes error as circumstances in which planned actions fail to achieve the desired outcome. Click here for more expanded definitions. “Human error” is a social label which implies that the individual should have acted differently, and thus is responsible for the consequence of that conduct. This is the basis of the “shame and blame” culture that has been so common in healthcare. (See module: Culture of Safety for more details.) There are many examples of human error in our everyday life: picking up a tube of ointment when we wanted toothpaste, clicking “send” on an e-mail before we meant to, or missing a stop sign at an intersection. In healthcare settings similar types of errors have even greater potential for harmful consequences. Providing healthcare will always involve humans in the decision-making and care delivery -- we hope! Each of us wants to provide the best patient care possible. Nonetheless, as humans we will make errors. It is important to acknowledge that fact when designing patient care processes. Systems must be created to prevent and/or catch the inevitable human errors before they result in harm. Questions about this website, please email: CFM_Webmaster@mc.duke.edu © 2016 Department of Community and Family Medicine, Duke University School of Medicine. All Rights Reserved.