Human Error Theory Research Articles

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.

A cognitive taxonomy of medical errors

Objective. Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. Design. Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. Measurements. Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. Results. The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. Conclusion. Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.

Causes of intravenous medication errors—observation of nurses in a German hospital

Aim Errors in the preparation and administration of intravenous (IV) drugs are frequent events. Human error theory has recently been applied to understand the causes of IV drug errors in an ethnographic study in the United Kingdom. We used this approach to explore causes of IV drug errors by nursing staff in a German hospital.

Cognitive flexibility and adaptability to environmental changes in dynamic complex problem-solving tasks

People who show good performance in dynamic complex problem-solving tasks can also make errors. Theories of human error fail to fully explain when and why good performers err. Some theories would predict that these errors are to some extent the consequence of the difficulties that people have in adapting to new and unexpected environmental conditions. However, such theories cannot explain why some new conditions lead to error, while others do not. There are also some theories that defend the notion that good performers are more cognitively flexible and better able to adapt to new environmental conditions. However, the fact is that they sometimes make errors when they face those new conditions. This paper describes one experiment and a research methodology designed to test the hypothesis that when people use a problem-solving strategy, their performance is only affected by those conditions which are relevant to that particular strategy. This hypothesis is derived from theories that explain human performance based on the interaction between cognitive mechanisms and environment.

Causes of prescribing errors in hospital inpatients: a prospective study

To prevent errors made during the prescription of drugs, we need to know why they arise. Theories of human error used to understand the causes of mistakes made in high-risk industries are being used in health-care. They have not, however, been applied to prescribing errors, which are a great cause of patient harm. Our aim was to use this approach to investigate the causes of such errors. Pharmacists at a UK teaching hospital prospectively identified 88 potentially serious prescribing errors. We interviewed the prescribers who made 44 of these, and analysed our findings with human error theory. Our results suggest that most mistakes were made because of slips in attention, or because prescribers did not apply relevant rules. Doctors identified many risk factors-work environment, workload, whether or not they were prescribing for their own patient, communication within their team, physical and mental well-being, and lack of knowledge. Organisational factors were also identified, and included inadequate training, low perceived importance of prescribing, a hierarchical medical team, and an absence of self-awareness of errors. To reduce prescribing errors, hospitals should train junior doctors in the principles of drug dosing before they start prescribing, and enforce good practice in documentation. They should also create a culture in which prescription writing is seen as important, and formally review interventions made by pharmacists, locum arrangements, and the workload of junior doctors, and make doctors aware of situations in which they are likely to commit errors.

The paradoxes of almost totally safe transportation systems

Safety remains driven by a simple principle: complete elimination of technical breakdowns and human errors. This article tries to put this common sense approach back into perspective in the case of ultra-safe systems, where the safety record reaches the mythical barrier of one disastrous accident per 10 million events (10 −7). Three messages are delivered: (1) the solutions aimed at improving safety depend on the global safety level of the system. When safety improves, the solutions used to improve the safety record should not be further optimised; they must continue to be implemented at present level (to maintain the safety health obtained), and supplemented further by new solutions (addition rather than optimisation rationale); (2) the maintenance and linear optimisation of solutions having dwindling effectiveness can result in a series of paradoxes eventually replacing the system at risk and jeopardising the safety record obtained in the first place; and (3) after quickly reviewing ambiguities in the definition of human error and the development of research in this area, this article shows, through recent industrial examples and surveys, that errors play an essential role in the acquisition and effectiveness of safety, at individual as well as collective levels. A truly ecological theory of human error is developed. Theories of error highlight the negative effects of an over-extensive linear extrapolation of protection measures. Similarly, it is argued that accepting the limitation of technical systems performance through the presence of a minimum breakdown and incident ‘noise’ could enhance safety by limiting the risks accepted. New research opportunities are outlined at the end of this paper, notably in the framework of systems now safe or ultra-safe.

Identifying Root Causes of Construction Accidents

Construction accident investigation techniques and reporting systems identify what type of accidents occur and how they occurred. Unfortunately, they do not properly address why the accident occurred by identifying possible root causes, which is only possible by complementing these techniques with theories of accident causation and theories of human error. The uniqueness of the construction industry dictates the need to tailor many of the contemporary accident causation models and human error theories. This paper presents an accident root causes tracing model (ARCTM) tailored to the needs of the construction industry. ARCTM proposes that accidents occur due to three root causes: (1) Failing to identify an unsafe condition that existed before an activity was started or that developed after an activity was started; (2) deciding to proceed with a work activity after the worker identifies an existing unsafe condition; and (3) deciding to act unsafe regardless of initial conditions of the work environment. In ...

Negative transfer errors in sequential cognitive skills: strong-but-wrong sequence application.

Three experiments investigated the role of processing sequence knowledge in negative transfer within multistep cognitive skills. In Experiments 1 and 2, more training resulted in higher error rates when new processing sequences that resembled familiar ones were introduced in transfer. Transfer error responses were executed with the same speed as correct responses to familiar sequence trials, and the errors appeared to be undetected by the performers. Experiment 3 tested whether the effects of sequence learning were attributable to explicit or implicit knowledge of processing sequences. Evidence favored the implicit learning interpretation. Findings are discussed in relationship to earlier demonstrations of the einstellung effect and to current taxonomic theories of human error.

Good practice in briefing: the limits of rationality

This paper identifies briefing as a persistent problem area for the construction industry and suggests that little development has occurred in briefing practice in 30 years. A research project is then described which aims to address the problem and lead to real improvements in briefing. Using techniques derived from grounded theory, initial results indicate that the issue is not simply a matter of good practice not being implemented—it is deeper than this, often involving the human dimension. This leads to an analysis of the problem in terms of human error theory and a discussion of the limits of the application of a rationalistic approach to briefing. Conclusions are drawn, pointing towards the need for new, richer perspectives to be taken if improvements in briefing are to be achieved in practice, or indeed in theory.

A Human Error Approach to Accident Investigation: The Taxonomy of Unsafe Operations

Human error continues to be implicated in the vast majority of aviation accidents. Yet, most accident investigation and reporting systems are not currently designed around any theoretical framework of human error. One reason may be the discontinuity between classical theories of human error and the practical application of these theoretical approaches in accident investigation. The Taxonomy of Unsafe Operations presented here bridges the gap between theory and practice by providing field investigators with a user-friendly, common-sense framework from which accident investigations can be conducted and human causal factors classified. This taxonomy draws upon traditional models of human error to account for human accident causal factors, including the condition of operators and supervisory error. A detailed description of the taxonomy is provided, as well as a discussion of the benefits it provides the field of accident investigation and prevention.

Modelling the Human Factor

Over the last 20 years major changes have occured in the Dutch sea fishing industry. Accident registration shows an increasing involvement of fishing vessels in collisions at sea, due to a number of factors. There is a need for modelling human behaviour especially with respect to the decision making and control strategies which are applied by the man on the bridge. By the application of human error theory to normative task analysis for the man on the bridge, insight is gained factors which may contribute to accidents. Requirements with respect to safety, mental load and human behaviour are formulated on the conceptual level. It gives a prospective tool to foresee use of a system before it becomes operational. Demands are put on workstation layout, technical equipment, procedures and training. Pilot studies concentrated on the structure of the information presentation and processing, the workstation layout and the vision lines inside and outside the bridge. Finally, the contribution discusses the strategies of a social and organizational nature, required for the approach of the residual risks and side effects involved with the chosen design solutions. Paper submitted to the 5th IFAC Conference, The Hague, The Netherlands, 9-11 June 1992.

An Experimental Approach to Validating a Theory of Human Error in Complex Systems

The problem of “human error” is pervasive in engineering systems in which the human is involved. In contrast to the common engineering approach of dealing with error probabilistically, the present research seeks to alleviate problems associated with error by gaining a greater understanding of causes and contributing factors from a human information processing perspective. The general approach involves identifying conditions which are hypothesized to contribute to errors, and experimentally creating the conditions in order to verify the hypotheses. The conceptual framework which serves as the basis for this research is discussed briefly, followed by a description of upcoming research. Finally, the potential relevance of this research to design, training, and aiding issues is discussed.