Human Performance and Patient Safety

Jim McMenemy

Winnipeg Regional Health Authority

Outline

• Human Factors definition• Human Error• Evolution of Human Error

Understanding• Organizations and Socio-technical

systems• Vulnerability and Countermeasures

Meaning of Human Factors

• What do we mean by “Human Factors”?– “Human Factors is concerned to optimize

the relationship between people and their activities, by the systematic application of human sciences, integrated within the framework of systems engineering.” (ICAO Digest No. 1)

Human Error

• Knowledge and Error flow from the same mental source; only success can tell one from the other.

Ernst Mach (1905)

Human Error

• What is Human Error?– Human Error is a generic term used to

describe all those occasions where a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to outside intervention (Reason, 1990).

Traditional Approach #1

• People make mistakes on the job because of:–Stupidity–Carelessness–Complacency–Incompetence, etc.

Traditional Error Prevention

• Make rules• Enforce rules• Punish violators

– Fire them– Suspend them– Retrain them– Counsel them

• If you follow the rules you cannot have an accident

Traditional Approach #2Humanistic

• Accidents happen because of Human Error

• People do not try to make mistakes• They must be Broken, defective,

deficient…..• Therefore “Fix the people”

Error Preventionby Fixing the People

• Decision-making training• Be more:

– Vigilant– Careful– More, more, more….

• But….– They weren’t broken

Human Error

• Why is the Old View so popular?– Cheap and easy– Saving face– Personal responsibility and the illusions of

omnipotence

Human Error

Basic Attribution Error:

Tendency to attribute behaviour to an enduring quality of the person

AND

Underestimate the influence of the situation.

Human Error

• Where the Old View falls short– Local rationality

• If your explanation still relies on unmotivated people, you have more work to do

• You have to assume that nobody comes to work to do a bad job

• You have to understand why what people did made sense to them at the time.

2006-11-03

Local Rationality

Human Error

“Underneath every simple, obvious story about error, there is a deeper, more complex story…”

“Take your pick: Blame human error or try to learn from failure…”

(Dekker, 2006)

Human Error

• New View of Human Error on what goes wrong:– Human Error is a symptom of trouble

deeper inside a system– To explain failure, do not try to find where

people went wrong– Instead, find out how people’s

assessments and actions made sense at the time given the circumstances that surrounded them

SabotageSubstance abuse

Reckless violationsetc.

System-induced violationsSystem-induced errors

etc.

Culpable Blameless

10% 90%

Human Error

Organizations andSocio-technical Systems

• Some system defences:– Physical design aspects– Job design elements– Adequate resources– Company safety management systems– Effective regulatory system– National legislation– International agreements…

Wiener's "Iron Law"

...if equipment is designed correctly for human use in the first place, the cost is high, but it is paid only once. If poor design must be compensated for in training departments and operations, the price must be paid every day. And what is worse, with weak, potentially error-inducing designs, one cannot be sure that when the chips are down, the correct responses will be made.

Wiener, Earl, L. (1993) Intervention Strategies for the Management of Human Error. NASA Contractor Report 4547. P. 13.

Error & Vulnerability

• Attention is a finite resource– Overload– Distraction– Interruption

• Fatigue – 17 hours = .05% BAC• Equipment design• Team coordination

Summary

• Meaning of Human Factors• Human Error• From Organizations to Socio-technical

Systems• Vulnerability & Countermeasures

Recommended Reading

• The Human Factor (Kim Vicente)• The Field Guide to Understanding Human

Error (Sidney Dekker)• Managing the Risks of Organizational

Accidents (James Reason)• 10 Questions About Human Error (Sidney

Dekker)