Human factors

Question 1

What are the 3 categories of error?

Answer 1

1. Action/skill based error
2. Thinking error
3. Non-compliance/violation

Question 2

What are the two types of action/skill based error?

Answer 2

Slips
Lapses

Question 3

What are the two types of thinking error?

Answer 3

Rule based
Knowledge based

Question 4

What are the 3 types of non-compliance / violation error?

Answer 4

1. Routine
2. Situation
3. Exceptional

Question 5

What is a slip and give examples

Answer 5

Not doing what you are meant to do

e.g. flashing headlight instead of using windscreen washer, take reading from wrong instrument

Question 6

What is a lapse and give examples

Answer 6

Short term memory lapse

e.g. forget to indicate at junction, forget to disconnect charge from charger before pulling off

Question 7

Describe slips and lapses and how they occur

Answer 7

Occur in very familiar tasks which we can carry out without much conscious attention

These tasks are very vulnerable to slips and lapses when our attention is diverted even for a moment.

Question 8

How can we reduces slips and lapses? (5)

Answer 8

1. Checklists
2. Reduce distractions
3. Human centred designs e.g. intuitive/user friendly
4. Warnings/alarms
5. Allow sufficient time to complete tasks

Question 9

Describe how thinking errors / mistakes occur?

Answer 9

Decision making failure, doing what you intended/planned but it is the wrong course of action

Question 10

What is a rule based error and give examples?

Answer 10

Behaviour is based on remembered rules and procedures, mistake
occurs due to mis-application of a good rule or application of a bad rule:

e.g. misjudge overtaking manoeuvre in unfamiliar, under-powered car
- assume £20 fuel will last a week but fail to account for rising prices
- ignore alarm in real emergency, following history of spurious alarms

Question 11

What is a knowledge based mistake and give examples?

Answer 11

Individual has no rules or routines available to handle an unusual situation: resorts to first principles and experience to solve problem:

e.g rely on out-of-date map to plan unfamiliar route
- misdiagnose process upset and take inappropriate corrective action
(due to lack of experience or insufficient / incorrect information etc.)

Question 12

How can we reduce thinking errors? (6)

Answer 12

1. plan for ‘what ifs’
2. regular drills/exercises for emergencies
3. clear overview / mental model (system feedback; effective shift handover etc.)
4. diagnostic tools and decision-making aids
5. competence (knowledge and understanding of
   system; training in decision-making techniques)
6. organisational learning

Question 13

What are violations/ non-compliance errors?

Answer 13

Deliberate deviations from rules, procedures, regulations. Knowingly take short cuts

Question 14

What is a routine non-compliance error/violation and give examples?

Answer 14

Becomes the ‘norm’; general consensus that rules no
longer apply; characterised by a lack of meaningful enforcement:

e.g high proportion of motorists drive at 80mph on the motorway

Question 15

What is a situation non-compliance error/violation and give examples?

Answer 15

Non-compliance dictated by situation-specific factors (time pressure;
workload; unsuitable tools & equipment; weather)

e.g van driver has no option but to speed to complete day’s deliveries

Question 16

What is an exceptional non-compliance error/violation?

Answer 16

Person attempts to solve problem in highly unusual circumstances (often if something has gone wrong); takes a calculated risk in breaking rules:

e.g. after a puncture, speed excessively to ensure not late for meeting

Question 17

How do you reduce non-compliance error/violations? (4)

Answer 17

1. improve risk perception
2. increase likelihood of getting caught
3. eliminate reasons to cut corners
4. improve attitudes / organisational culture

Question 18

What is ‘anchoring bias?’

Answer 18

Being excessively influences by one element of the presented information, which subsequently biases the interpretation of the later information

Question 19

What is availability bias?

Answer 19

Choosing a particular diagnosis/interpretation because it is at the front of mind (including frequency and recency bias)

Question 20

What is premature closure?

Answer 20

Arriving at a conclusion or diagnosis before all the options have been considered

Question 21

What is confirmation bias?

Answer 21

Seeking or prioritising information that confirms current or desired thinking rather than considering all the information

Question 22

What is framing effect?

Answer 22

The order or way with which initial information is presented ‘frames’ or biases the way subsequent information is interpreted

Question 23

What is commission bias?

Answer 23

The tendency to act rather than not to act, hence motivating unneeded treatments or actions.

Question 24

What is overconfidence bias?

Answer 24

The common tendency to believe we know more than we do, or that we are all better-than-average practitioners. May lead to action based on incomplete information
or hunches, rather than carefully gathered evidence.

Question 25

What is omission bias?

Answer 25

Tendency not to act when intervention is indicated, for example a hesitancy to initiate emergency measures because of worries about being wrong or harming the patient.

Question 26

Describe the ‘sunk costs’

Answer 26

Unwillingness to give up on a poor conclusion or diagnosis as much time or resource has been invested in developing it

Question 27

What are the 7 pillars of clinical governance?

Answer 27

1. Service user involvement
2. HR management
3. Personal and professional development
4. Clinical effectiveness
5. Clinical audit
6. Risk management
7. Clinical information management