The psychology of error
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The Psychology of Error. Dr Maria Woloshynowych Imperial College, London META Network - Medication Error research meeting 3-4 March 2004. Human error. “We all make errors irrespective of how much training and experience we possess or how motivated we are to do it right”

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The psychology of error l.jpg

The Psychology of Error

Dr Maria Woloshynowych

Imperial College, London

META Network - Medication Error research meeting 3-4 March 2004


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Human error

“We all make errors irrespective of how much training and experience we possess or how motivated we are to do it right”

From Reducing error and influencing behaviour, HSE. 1999


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Some myths about errors

  • Good people do not make mistakes

  • Errors and mistakes are intentional

    NB. Often actions, including violations are carried with the best intentions - exceptions

  • There is always someone to blame

  • Symmetry between action (cause) and consequence

  • Illusion of free will – we are in complete control of our actions and situations


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Error in context

The individual

  • Models and theories of human error

    The context

  • Immediate environment

  • Tasks

  • Teams

  • Organisation


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Types of errors

Slips/lapses (execution failures):

  • Skill based - recognition, attention, memory or selection failure

    Mistakes (planning or problem-solving failures):

  • Rule based (e.g. misapplication of a good rule)

  • Knowledgebased - occur in novel situations, use of inaccurate or incomplete mental models and subject to biases


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Human performance

Physiological factors

  • Fatigue, sleep, hunger, state of health

    Emotional factors

  • Mood states (e.g. anxiety), life events, confidence, motivation, personality

    Cognitivefactors

  • Thought processes involved in tasks including cognitive biases

    Stress: difficult or novel tasks, work load interruptions, urgent tasks, etc.


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Model of an organisational accident

Contributory factors influencing clinical practice

Organisational & Corporate Culture

Defence Barriers

Task

Accident / Incident

Error Producing Conditions

Errors

Management Decisions and Organisational Processes

Violation Producing Conditions

Violations

Latent failures in defences

Adapted from Reason (1990)


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Latent failures

  • Adverse consequences which lay dormant within the system for a long time, only becoming evident when they combine with other factors to break through the system’s defences

  • These are committed by those far removed in time and space from the immediate area: - designers, high-level decision makers, managers and maintenance personnel.

  • Decisions are shaped by various factors: - economic, political, practical constraints.


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Active failures

Unsafe acts committed by those at the sharp end (surgeons, physicians anaesthetists, nurses, etc.)

These actions can have immediate adverse consequences (e.g. administering the wrong drug, dose, or route)

Latent failures

Created as a result of decisions taken at the highest levels of the organisation (e.g. staffing levels, choice of equipment)

Their damaging consequences become evident when they combine with local trigger factors

Differences


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Framework for the analysis of risk and safety in medicine

  • Patient factors

  • Task factors

  • Individual staff factors

  • Team Factors

  • Work environment

  • Organisation and management

  • Institutional context

Vincent et al., 1998


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Framework for the analysis of risk and safety in medicine

  • Patient factors - medical condition, language, personality

  • Task factors - task design, decision-making aids availability & use of protocols,

  • Individual (staff) factors - knowledge, skills, health

  • Team factors - communication, supervision, leadership


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Framework for the analysis of risk and safety in medicine

  • Environment - workload, skill mix, equipment

  • Organisational - financial resources,

    & managementpolicy, standards, safety culture

  • Institutional context - NHS executive, regulatory context


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Person versus System view of error

Person Centred View

  • Focus on the individual, excluding other factors

  • Individual responsibility and blame - careless, at fault, ‘bad’

  • Solution: change behaviour / remove the individual

    System View

  • Focus on factors that influence errors

  • Human beings are fallible, errors to be expected

  • Solution: change system / conditions of work


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