Human factors Flashcards
What are the 3 categories of error?
- Action/skill based error
- Thinking error
- Non-compliance/violation
What are the two types of action/skill based error?
Slips
Lapses
What are the two types of thinking error?
Rule based
Knowledge based
What are the 3 types of non-compliance / violation error?
- Routine
- Situation
- Exceptional
What is a slip and give examples
Not doing what you are meant to do
e.g. flashing headlight instead of using windscreen washer, take reading from wrong instrument
What is a lapse and give examples
Short term memory lapse
e.g. forget to indicate at junction, forget to disconnect charge from charger before pulling off
Describe slips and lapses and how they occur
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.
How can we reduces slips and lapses? (5)
- Checklists
- Reduce distractions
- Human centred designs e.g. intuitive/user friendly
- Warnings/alarms
- Allow sufficient time to complete tasks
Describe how thinking errors / mistakes occur?
Decision making failure, doing what you intended/planned but it is the wrong course of action
What is a rule based error and give examples?
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
What is a knowledge based mistake and give examples?
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e.g rely on out-of-date map to plan unfamiliar route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.)
How can we reduce thinking errors? (6)
- plan for ‘what ifs’
- regular drills/exercises for emergencies
- clear overview / mental model (system feedback; effective shift handover etc.)
- diagnostic tools and decision-making aids
- competence (knowledge and understanding of
system; training in decision-making techniques) - organisational learning
What are violations/ non-compliance errors?
Deliberate deviations from rules, procedures, regulations. Knowingly take short cuts
What is a routine non-compliance error/violation and give examples?
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
What is a situation non-compliance error/violation and give examples?
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
What is an exceptional non-compliance error/violation?
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
How do you reduce non-compliance error/violations? (4)
- improve risk perception
- increase likelihood of getting caught
- eliminate reasons to cut corners
- improve attitudes / organisational culture
What is ‘anchoring bias?’
Being excessively influences by one element of the presented information, which subsequently biases the interpretation of the later information
What is availability bias?
Choosing a particular diagnosis/interpretation because it is at the front of mind (including frequency and recency bias)
What is premature closure?
Arriving at a conclusion or diagnosis before all the options have been considered
What is confirmation bias?
Seeking or prioritising information that confirms current or desired thinking rather than considering all the information
What is framing effect?
The order or way with which initial information is presented ‘frames’ or biases the way subsequent information is interpreted
What is commission bias?
The tendency to act rather than not to act, hence motivating unneeded treatments or actions.
What is overconfidence bias?
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.
What is omission bias?
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.
Describe the ‘sunk costs’
Unwillingness to give up on a poor conclusion or diagnosis as much time or resource has been invested in developing it
What are the 7 pillars of clinical governance?
- Service user involvement
- HR management
- Personal and professional development
- Clinical effectiveness
- Clinical audit
- Risk management
- Clinical information management
