Topic 5 Understanding and and learning from error. Learning objective. Understand the nature of error and how health care can learn from error to improve patient safety. Knowledge requirement. Explain the terms error, violation, near miss, hindsight bias. Performance requirements:.
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and learning from error
Understand the nature of error and how health care can learn from error to improve patient safety
Explain the terms error, violation,
near miss, hindsight bias
a simple definition is:
a more formal definition is:
A deliberate deviation from an accepted protocol or standard of care
Human factors principles
One definition of “human error”
is “human nature”.
Think about and then discuss with your colleagues any
“silly” mistakes you have made recently when you
were not in your place of work or study - and why
you think they happened
Regardless of their experience, intelligence, motivation or vigilance, people make mistakes
* Especially if combined with lack of supervision
Am I safe to work today?
Before the Incident
After the Incident
Modified from Cook, 1997
Shared values (what is important) and
beliefs (how things work) that interact
with an organization’s structure and
control systems to produce behavioural
norms (the way we do things around here)
Established by the US Department of
National Center for Patient Safety
Getting the balance right