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'?

60-80% Signup and view all the answers

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

Clinical error Signup and view all the answers

Why do humans make mistakes?

Because they are fallible Signup and view all the answers

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

TMI accident Signup and view all the answers

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

Lapses Signup and view all the answers

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

To explain accidents Signup and view all the answers

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

Risø, Denmark Signup and view all the answers

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

Use of everyday errors versus complex systems analysis 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?

Violations Signup and view all the answers

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

Human failure Signup and view all the answers

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

To verify the medication and its administration Signup and view all the answers

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

James Reason Signup and view all the answers

What is a factor that can contribute to medication errors?

Multiple tasks Signup and view all the answers

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

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

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

Two Signup and view all the answers

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

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

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

Slip Signup and view all the answers

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

Knowledge-based Signup and view all the answers

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

When there is an undesired event or outcome 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?

A drug error during medication administration Signup and view all the answers

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

It oversimplifies the complexity of the incident Signup and view all the answers

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

The complex interactions between actors in space and time Signup and view all the answers

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

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

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

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

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

How people and machines interact and what constrains human action Signup and view all the answers

What does the naturalistic school see human error as?

A symptom of underlying problems Signup and view all the answers

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

It is always variable and adjusting to conditions 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.