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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.

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Human performance and patient safety

Human Performance and Patient Safety

Jim McMenemy

Winnipeg Regional Health Authority


  • Human Factors definition

  • Human Error

  • Evolution of Human Error Understanding

  • Organizations and Socio-technical systems

  • Vulnerability and Countermeasures

Meaning of human factors
Meaning of Human Factors

  • What do we mean by “Human Factors”?

    • “Human Factors is concerned to optimize the relationship between people and their activities, by the systematic application of human sciences, integrated within the framework of systems engineering.” (ICAO Digest No. 1)

Human Error

  • Knowledge and Error flow from the same mental source; only success can tell one from the other.

    Ernst Mach (1905)

Human error
Human Error

  • What is Human Error?

    • Human Error is a generic term used to describe all those occasions where a planned sequence of mental or physical activities fails to achieve its intended outcome, and when these failures cannot be attributed to outside intervention (Reason, 1990).

Traditional approach 1
Traditional Approach #1

  • People make mistakes on the job because of:

    • Stupidity

    • Carelessness

    • Complacency

    • Incompetence, etc.

Traditional error prevention
Traditional Error Prevention

  • Make rules

  • Enforce rules

  • Punish violators

    • Fire them

    • Suspend them

    • Retrain them

    • Counsel them

  • If you follow the rules you cannot have an accident

Traditional approach 2 humanistic
Traditional Approach #2Humanistic

  • Accidents happen because of Human Error

  • People do not try to make mistakes

  • They must be Broken, defective, deficient…..

  • Therefore “Fix the people”

Error prevention by fixing the people
Error Preventionby Fixing the People

  • Decision-making training

  • Be more:

    • Vigilant

    • Careful

    • More, more, more….

  • But….

    • They weren’t broken

Human error1
Human Error

  • Why is the Old View so popular?

    • Cheap and easy

    • Saving face

    • Personal responsibility and the illusions of omnipotence

Human error2
Human Error

Basic Attribution Error:

Tendency to attribute behaviour to an enduring quality of the person


Underestimate the influence of the situation.

Human error3
Human Error

  • Where the Old View falls short

    • Local rationality

      • If your explanation still relies on unmotivated people, you have more work to do

      • You have to assume that nobody comes to work to do a bad job

      • You have to understand why what people did made sense to them at the time.

Local rationality
Local Rationality


Human error4
Human Error

“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…”

(Dekker, 2006)

Human error5
Human Error

  • New View of Human Error on what goes wrong:

    • Human Error is a symptom of trouble deeper inside a system

    • To explain failure, do not try to find where people went wrong

    • Instead, find out how people’s assessments and actions made sense at the time given the circumstances that surrounded them

Human Error






Substance abuse

Reckless violations


System-induced violations

System-induced errors


Organizations and socio technical systems
Organizations andSocio-technical Systems

  • Some system defences:

    • Physical design aspects

    • Job design elements

    • Adequate resources

    • Company safety management systems

    • Effective regulatory system

    • National legislation

    • International agreements…

Wiener's "Iron Law"

...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.

Error vulnerability
Error & Vulnerability

  • Attention is a finite resource

    • Overload

    • Distraction

    • Interruption

  • Fatigue – 17 hours = .05% BAC

  • Equipment design

  • Team coordination


  • Meaning of Human Factors

  • Human Error

  • From Organizations to Socio-technical Systems

  • Vulnerability & Countermeasures

Recommended reading
Recommended Reading

  • The Human Factor (Kim Vicente)

  • The Field Guide to Understanding Human Error (Sidney Dekker)

  • Managing the Risks of Organizational Accidents (James Reason)

  • 10 Questions About Human Error (Sidney Dekker)