Highlights

  • It is easier to place individual blame over system analysis and change. This requires management to accept responsibility for the error through system failure.
  • “Five specific mechanisms that should be used to design out error: reduced reliance on memory, improved information access, error proofing, standardization and training.”
  • “Limit the expectations and discretion of practitioners; reduce professional autonomy, (and consequently) shift from a hierarchical mindset to professional equivalence; system leadership; and simplification of professional rules and ways of working.”
  • See Group Think for more…

Synopsis

Memory is biased towards over-generalization.

“Slip: a potentially observable error which results from failure in the execution and/or storage stage of an action, regardless of the original plans adequacy.”

“Lapse: predominantly related to memory failure, a less observable error which may only be apparent to the protagonist which also results from failure of the execution and/or storage stage of an action, regardless of the original plans adequacy.”

“Mistake: a deficiency or failure in the judgemental or inferential processes involved in selecting an objective or means of achieving it, regardless of the outcome of any actions.”

“Errors generally part of developmental or adaptive process, individual frequently resorting to cognitive shortcuts to find easier way to complete task.”

“Contributing factors such as communication, teamwork difficulties, and lack of training are not uncommon across many documented incidents.”

An individual may be to blame, however, it may be a manifestation of a systemic issue. It is easier and less expensive to assign blame to an individual. Human error is likely a contributing factor, but unlikely to be the only factor.

Systemic investigation is time consuming and costly to implement changes. Management has to accept responsibility, and management may be unwilling to accept associated blame or failure.

“The error-wise practitioner who reduces but knowingly does not entirely eliminate their propensity to err, will assess their own ability to undertake a given task, assess the environment, but also analyze the task and assess its error potential.”

“Five specific mechanisms that should be used to design out error: reduced reliance on memory, improved information access, error proofing, standardization and training.”

“Limit the expectations and discretion of practitioners; reduce professional autonomy, (and consequently) shift from a hierarchical mindset to professional equivalence; system leadership; and simplification of professional rules and ways of working.”

Human error theory: relevance to nurse management [PDF]


References

Armitage, G. (2009). Human error theory: relevance to nurse management. Journal Of Nursing Management, 17(2), 193-202. doi:10.1111/j.1365-2834.2009.00970.x