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.
Winnipeg Regional Health Authority
Ernst Mach (1905)
Basic Attribution Error:
Tendency to attribute behaviour to an enduring quality of the person
Underestimate the influence of the situation.
“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…”
...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.