LIT 7 - Reason Human Error Flashcards
Reason: What is the primary focus of the person approach to human error, and what are some typical countermeasures?
The person approach focuses on the individual when something goes wrong, attributing errors to unsafe acts by people at the ‘sharp end’. Typical countermeasures include putting up posters, writing more rules, punishing individuals, providing more training, and blaming or shaming them.
The underlying assumption can be that ‘bad things happen to bad people’, known as the just world hypothesis.
Reason: What is the core idea of the system approach to human error, and what is the focus of its countermeasures?
The system approach examines the broader system in which errors occur, recognizing that mistakes are inevitable in human operations. It focuses on changing conditions rather than fixing individuals. Countermeasures aim to improve system defences and address upstream factors.
The focus shifts from ‘who messed up?’ to ‘how and why did the defences fail?’.
Reason: According to the system approach, what is the crucial element in preventing adverse events?
The system approach emphasizes system defences, which are layers of protection designed to catch mistakes before they cause harm. These can include protocols, alarms, and checks.
The goal is to protect people and assets from potential dangers.
Reason: Explain the Swiss cheese model of system accidents.
The Swiss cheese model visualizes accidents as occurring when holes in multiple layers of defence align, allowing hazards to pass through. Each slice of cheese represents a defence layer, and the holes symbolize weaknesses.
An accident results from a combination of failures across the system’s defences.
Reason: What are active failures, and what is their typical impact?
Active failures are unsafe acts committed by individuals directly involved in a situation, such as slips or lapses in judgment. They typically have a direct and immediate impact on safety.
An example is a nurse giving the wrong medication dose.
Reason: What are latent conditions, and how do they contribute to accidents?
Latent conditions are hidden weaknesses within a system, often resulting from earlier decisions made by distant individuals. They can create an environment conducive to errors and may lie dormant until combined with active failures.
Examples include unrealistic time pressure and inadequate equipment.
Reason: Why is a reporting culture important for effective risk management, and what is essential for its existence?
A reporting culture is vital for safety improvement, allowing organizations to learn from errors and near misses. Trust is essential for its existence, enabling individuals to report without fear of blame.
A ‘just culture’ is necessary, distinguishing between blameless actions and those that are blameworthy.
Reason: What are high reliability organisations, and what is a key characteristic of their approach to human variability?
High reliability organisations (HROs) operate in hazardous environments with fewer accidents by understanding human variability as a safeguard rather than a problem. They maintain a state of ‘intelligent wariness’.
Reliability is viewed as a ‘dynamic non-event’, achieved through timely human adjustments.
Reason: What is a significant distinguishing feature of high reliability organisations regarding their attitude towards failure?
HROs have a constant focus on the possibility of failure, expecting errors and training to recognize and recover from them. They proactively seek to improve the system’s robustness against potential hazards.
This proactive approach is a hallmark of highly reliable systems.
Briefly explain the two approaches Reason distinguishes for human error. (10 points)
Here’s a summary of the two approaches to human error in bullet points:
Person Approach:
* Focuses on unsafe acts (errors, violations) of individuals at the sharp end.
* Views these acts as arising from aberrant mental processes (forgetfulness, inattention, etc.).
* Countermeasures target reducing unwanted variability in human behaviour.
* Methods include poster campaigns, new procedures, disciplinary measures, retraining, blaming.
* Often treats errors as moral issues based on the “just world hypothesis”.
* Remains the dominant tradition in medicine.
* Blaming individuals is emotionally more satisfying than targeting institutions.
* Managers find it in their interests to uncouple individual acts from institutional responsibility.
* Legally more convenient, at least in Britain.
* Has serious shortcomings and is ill-suited to the medical domain.
* The majority of unsafe acts are not egregious.
* Isolates unsafe acts from their system context.
* Overlooks that the best people can make mistakes.
* Fails to seek out and remove error-provoking properties in the system.
System Approach:
* Premise: humans are fallible, errors are expected.
* Sees errors as consequences of “upstream” systemic factors.
* Focuses on recurrent error traps and organisational processes.
* Countermeasures aim to change the conditions under which humans work.
* Central idea is system defences and why they fail during adverse events.
* High reliability organisations exemplify this approach.
* Recognises human variability can be harnessed to avert errors.
* Employs the Swiss cheese model of system accidents, where defences have holes.
* Holes in defences arise from active failures and latent conditions.
* Error management aims to limit dangerous errors and create error-tolerant systems.
* Targets the person, team, task, workplace, and institution.
* Focuses on proactive risk management by identifying and remedying latent conditions.
* Seeks system reforms rather than local repairs after failures.
