4. Human Error

Hi everyone, 
This week I have been thinking a lot about human error. This is such a key factor in many of the problems that occur in medicine. What strikes me most about it is that many of our approaches to thinking are active in their nature. We focus on what we can do and what we can influence. However, there is often a much more important negative dimension. By this, I mean the things that we fail to do, or do without cognitive intent. Despite the relative lack of focus, this is probably the mechanism behind most of our problems. It is much less common that we actively make bad decisions. Instead, it is the mistakes, slips, lapses, and other forms of error that lead to the problem. This is why they often sneak up on us, occurring out of the blue.

But despite their ‘negative’ nature that doesn't mean that they are out of our control. It does mean that we have to think quite differently about them. I do believe that we are excessively focused on the rational and conscious mind, and give it far too much respect and credit. This is part of the way we train - we are educated to be effective clinicians that are skilled and knowledgeable enough to not make errors. But this runs against many of the things we know about human psychology, not to mention the evidence of reducing error. Instead, we need to be very aware of the many other contributing factors.

The field of human factors (also termed ergonomics) often actively tries to minimise the human component of performance. That is, the goal is to engineer systems that are robust enough to cope with the many different ways in which things can go wrong - basically, foolproof. It is this focus on systems thinking that I find both interesting and empowering. The “hierarchy of controls” model highlights how we should be focused on the design of systems and equipment to maximise safety, with the decreasingly effective addition of barriers, mitigations, and finally education and training.

Of particular note, it should cause us to really reassess the way we think about error, especially in others. There is a great tendency for attributing blame, and for the corresponding feelings of guilt and shame. However, outside of deliberate acts of action or gross negligence, these don't fit well with reality. It is actually the many latent failures of the system that we should be interested in. These have likely failed thousands of times before the ultimate fateful failure that included human error. 

This leads on to the potential positive impact that we can have. Instead of responding to mistakes with some vague resolve to do better, we should be more analytical. We should aim to look at the systems within which we were operating, and the ways that they could be better designed to help us. For instance, if we keep forgetting something, how can we use technology, or environmental design to make it impossible for us to forget (or not need to remember)? We will find that this is far more effective and easier than simply willing ourselves (or even actively training ourselves) to not make mistakes. 

The Association of Anaesthetists have produced this very good summary of how we can better incorporate human factors into our work. It is well worth checking out. For me, I am finding myself moving away from some of my previous focus on training, and instead a bigger focus on the nature and design of the systems themselves. This is often challenging because some of these things we can have less of an impact on, but there are often still many factors that we can influence. Indeed, some of the systems can probably be on a micro level (the way we set up our theatre environment) and add benefit in additional to the large scale changes that are the most needed. Regardless, I am convinced it is an area that needs to be much more at the centre of how we practice. I’m very interested to hear your thoughts.

BW

Tom    

“Knowledge and error flow from the same mental sources, only success can tell the one from the other.”

• Ernst Mach

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