Introduction to Human Errors in Industrial Accidents

Causal Factors in Accidents

• Human error is frequently cited as a primary cause of accidents across various industries.
• The concept of human error gained traction in scientific study and intervention within safety sciences starting in the 1970s.

Human Error in Adverse Events

• The term 'human error' is linked to negative outcomes due to its association with mistakes made by individuals during critical processes.
• Research indicates that approximately 70% of adverse events in healthcare might involve some form of human error.
• A synonym for 'human error' in the context of healthcare is 'clinical error'.

Reasons for Human Mistakes

• Mistakes stem from cognitive limitations, environmental factors, stress, and inadequate training or resources.
• James Reason's interest in operator errors in high-risk processes was sparked by the 1981 Three Mile Island nuclear incident.

James Reason's Error Categorization

• James Reason defined "lapses" as failures of memory within his framework for categorizing errors.
• The categorization of human error serves to enhance understanding and prevention strategies within safety protocols.

Development of Human Error Schools

• The joint cognitive systems school of thought originated in the fields of human factors engineering and cognitive psychology.
• James Reason's approach focuses on systematic understanding of human error, while the joint cognitive systems school emphasizes the interplay between humans and the systems they operate within.

Types of Errors

• Reason categorized violations of rules or procedures as "rule-based errors."
• Medication misadventures are widely recognized as a fundamental 'root cause' of medication errors.

Goals and Contributors in Healthcare

• Clinicians prioritize patient safety and effective treatment when administering medications.
• Daniel Kahneman is a prominent psychologist recognized for his contributions to the Cognitive Psychological perspective on human error.

Factors Influencing Medication Errors

• Factors such as workload, distractions, and poor communication can lead to medication errors.
• When a medication error is ascribed to human failure, it often results in heightened blame and scrutiny of healthcare professionals.

Schools of Thought on Errors

• Three primary schools of thought emerged within the study of medication errors.
• Errors are conceptualized as integral to human performance, emphasizing the inevitability of human mistakes.

Performance Levels and Errors

• A mistake occurs when a planned action unfolds incorrectly, despite having devised a suitable plan.
• According to Rasmussen’s model, the highest level of performance is termed "skill-based".

Error Identification Challenges

• A paramedic's decision or action constitutes an 'error' if it deviates from established protocols or expected outcomes.
• Identifying an incident as 'human error' poses challenges, as it may oversimplify complex situations.

Focus of the Naturalistic School

• The naturalistic school opted against viewing errors merely as psychological constructs, focusing instead on real-world decision-making contexts.
• This school reasoned that human error is often a natural outcome of cognitive limitations within varying environments.

Hollnagel's Perspective on Human Error

• Hollnagel proposed a 'no view' concept, suggesting that error cannot be solely defined by individual actions but must include the system context.
• The naturalistic school sought to comprehend human error as a dynamic interaction between system design, environment, and human capabilities.

Key Characteristics of Human Activity

• According to Hollnagel's model, a key characteristic of human activity is its variability, highlighting that performance can differ depending on numerous situational factors.

Learn about the concept of human error, its history, and its significance in industrial accidents. Discover how human error became a target of scientific study and intervention in the broader safety sciences. Test your knowledge on human error and its role in various industries.