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.

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