Review: Avoid, trap, and mitigate - an overview of threat and error management.

Abstract

Human error is as old as humanity itself and occurs on a daily basis, whatever we are doing. Recognising our fallibility is the first step to understanding error and ways to reduce it. The term "never event" is, therefore, a misnomer as these serious adverse incidents can never be eliminated completely. Up to 1 in 20 hospital admissions includes some form of error, and while many have little detrimental effect on patients' care (such as forgetting to write a discharge summary), 6% are serious. Many medical errors could have been prevented through the understanding and application of human factors (HF) including (but not exclusively) better team working, situational awareness, and the lowering of authority gradients. In this article we provide an overview of error and introduce the concept of threat and error management (TEM) which is used in other, high-reliability organisations, and provides three layers of defence to reduce the effect or severity of any error. We discuss how to try and avoid medical error in the first place (the first line of defence), trap errors when they occur, and mitigate the consequences of any error to help further safeguard our patients.