Lapse Error Definition
Contents |
navigation, searchHERE Article Information Category: Human Behaviour Content source: SKYbrary Content control: SKYbrary Contents 1 Definition 2 Description 3 Slips and Lapses 3.1 Examples of slips and lapses in aviation 4 Mistakes 4.1 Example of mistake 5 Error
Example Of Human Error
frequencies 6 Error detection and correction 7 Related Articles 8 Further Reading Definition Errors types of human error in aviation are the result of actions that fail to generate the intended outcomes. They are categorized according to the cognitive processes involved towards types of human error at workplace the goal of the action and according to whether they are related to planning or execution of the activity. Description Actions by human operators can fail to achieve their goal in two different ways: The
Rule Based Error
actions can go as planned, but the plan can be inadequate, or the plan can be satisfactory, but the performance can still be deficient (Hollnagel, 1993). Errors can be broadly distinguished in two categories: Category 1 - A person intends to carry out an action, the action is appropriate, carries it out incorrectly, and the desired goal is not achieved. - An execution failure has occurred. Execution errors are called Slips and
Human Error In Experiments
Lapses. They result from failures in the execution and/or storage stage of an action sequence. Slips relate to observable actions and are commonly associated with attentional or perceptual failures. Lapses are more internal events and generally involve failures of memory. Category 2 - A person intends to carry out an action, does so correctly, the action is inappropriate, and the desired goal is not achieved - A planning failure has occurred. Planning failures are Mistakes. “Mistakes may be defined as deficiencies or failures in the judgmental and/or inferential processes involved in the selection of an objective or in the specification of the means to achieve it.” (Reason, 1990). Execution errors correspond to the Skill based level of Rasmussen’s levels of performance (Rasmussen 1986), while planning errors correspond to the Rule and Knowledge-based levels (see Figure 1) Figure 1: execution and planning failures adapted from Rasmussen Slips and Lapses In a familiar and anticipated situation people perform a skill-based behaviour. At this level, they can commit skill-based errors (slips or lapses). In the case of slips and lapses, the person’s intentions were correct, but the execution of the action was flawed - done incorrectly, or not done at all. This distinction, between being done incorrectly or not at all, is another important discriminato
Principles Summary Types of Errors Reason classified errors based on Rasmussen’s 3 human error synonym levels of performance Skill-based errors – slips and lapses –
4 Types Of Human Error
when the action made is not what was intended Rule-based mistakes – actions that four types of human error match intentions but do not achieve their intended outcome due to incorrect application of a rule or inadequacy of the plan. Knowledge-based mistakes http://www.skybrary.aero/index.php/Human_Error_Types – 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 http://patientsafetyed.duhs.duke.edu/module_e/types_errors.html 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.
| No comments While the consequences of medical errors can be devastating, in reality, medical errors are not unique. Medical errors are http://www.humanfactorsmd.com/psychology-of-human-error/ simply errors in a medical context. As such, we can turn to what we know about the nature of human error in general to understand why medical errors occur, what factors produce them, and how to design to reduce them. Slips, Lapses and Mistakes Cognitive psychologists distinguish between "skill-based" performance, "rule-based" performance, and "knowledge-based" performance. human error Skills are highly practiced behaviors that we perform routinely, with little conscious effort. They're literally automatic. Rule and knowledge-based performance require more mental involvement or conscious deliberation. We rely on them when skill-based performance won't work, typically in exceptional or novel situations. Slips and lapses are errors in the performance of skill-based behaviors, typically when our of human error attention is diverted. A common mechanism for a slip is "capture", in which a more frequently performed behavior "takes-over" a similar, but less familiar one. For example, a capture error is made when a nurse misprograms a new infusion pump because the sequence of steps is similar, but not identical to the pump he is most familiar with. Description errors are slips that occur when the objects of different actions are close together or visually similar, as when the wrong control on an EKG is adjusted because it's close to other controls that look the same. Loss of activation errors are lapses where the goal is forgotten in the middle of a sequence of actions (e.g., a radiologists forgetting what he is looking for after retrieving and displaying a comparison study), or we omit a step in a routine sequence (e.g., the failure to complete a "double-check" for blood-type in an organ transfer protocol). Slips and lapses occur while our attention is diverted and
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