Introduction to Human Errors in Industrial Accidents
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Questions and Answers

What is often mentioned as a causal factor in accidents in various industries?

  • Lack of training
  • Environmental factors
  • Human error (correct)
  • Machine failure

    • When did the concept of human error become a significant area of scientific study and intervention in the broader safety sciences?

  • After the Three Mile Island nuclear meltdown accident in 1979 (correct)
  • Early 1900s
  • After World War II
  • In the 1980s

    • Why is the term 'human error' associated with adverse events?

  • Because it is a minor issue
  • Because it implies a failure caused by the human (correct)
  • Because it is a rare occurrence
  • Because it is a machine-related problem

    • According to studies, what percentage of adverse events in healthcare could involve 'human error'?

    <p>60-80%</p> Signup and view all the answers

    What is a synonym for 'human error' in the context of healthcare?

    <p>Clinical error</p> Signup and view all the answers

    Why do humans make mistakes?

    <p>Because they are fallible</p> Signup and view all the answers

    What event sparked James Reason's interest in errors made by operators of high-risk processes?

    <p>TMI accident</p> Signup and view all the answers

    What is the term used by James Reason to describe failures of memory in his error categorization system?

    <p>Lapses</p> Signup and view all the answers

    According to James Reason, what is the purpose of categorizing human error?

    <p>To explain accidents</p> Signup and view all the answers

    Where did the joint cognitive systems school of human error develop?

    <p>Risø, Denmark</p> Signup and view all the answers

    What is the main difference between James Reason's approach and the joint cognitive systems school?

    <p>Use of everyday errors versus complex systems analysis</p> Signup and view all the answers

    What is the term used by James Reason to describe errors that involve a violation of a rule or procedure?

    <p>Violations</p> Signup and view all the answers

    What is a commonly cited 'root cause' of medication errors?

    <p>Human failure</p> Signup and view all the answers

    What is the primary goal of a clinician when administering medication?

    <p>To verify the medication and its administration</p> Signup and view all the answers

    Who is a prominent psychologist associated with the Cognitive Psychological school of human error?

    <p>James Reason</p> Signup and view all the answers

    What is a factor that can contribute to medication errors?

    <p>Multiple tasks</p> Signup and view all the answers

    What is a common outcome when a medication error is attributed to human failure?

    <p>The individual is given feedback to 'be more careful' in the future</p> Signup and view all the answers

    How many schools of thought emerged in the study of medication errors?

    <p>Two</p> Signup and view all the answers

    What is error referred to as in the context of human performance?

    <p>A generic term to encompass all occasions of failure in achieving intended outcome</p> Signup and view all the answers

    What type of error occurs when a correct plan is devised but actions do not go as planned?

    <p>Slip</p> Signup and view all the answers

    According to Rasmussen's (1983) levels of performance, what is the highest level of performance?

    <p>Knowledge-based</p> Signup and view all the answers

    When would a paramedic's decision or action be considered an 'error'?

    <p>When there is an undesired event or outcome</p> Signup and view all the answers

    What is an example of an incident that could be identified as 'human error' in a pre-hospital setting?

    <p>A drug error during medication administration</p> Signup and view all the answers

    What is the main issue with identifying an incident as 'human error'?

    <p>It oversimplifies the complexity of the incident</p> Signup and view all the answers

    What did the naturalistic school focus on instead of studying errors as a psychological or cognitive construct?

    <p>The complex interactions between actors in space and time</p> Signup and view all the answers

    What conclusion did the naturalistic school arrive at regarding human error?

    <p>Human error is a symptom of deeper problems in the system</p> Signup and view all the answers

    What does Hollnagel's 'no view' of human error propose?

    <p>That the term 'human error' is not meaningful and should be abandoned</p> Signup and view all the answers

    What do the naturalistic school's questions regarding human error aim to understand?

    <p>How people and machines interact and what constrains human action</p> Signup and view all the answers

    What does the naturalistic school see human error as?

    <p>A symptom of underlying problems</p> Signup and view all the answers

    What is a key characteristic of human activity according to Hollnagel's 'no view'?

    <p>It is always variable and adjusting to conditions</p> Signup and view all the answers

    Study Notes

    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.

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    Description

    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.

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