Human Error in Medicine

By Marilyn Sue Bogner | Go to book overview

4
Human Errors: Their Causes and Reduction

Harold Van Cott Van Cott and Associates

"Human Error: Avoidable Mistakes Kill 100,000 Patients a Year" ( Russell, 1992): Headlines about human error in hospitals, railroads, and chemical and nuclear power plants have become everyday breakfast-table news, but they are neither inevitable nor unavoidable.

The goal of this chapter is to examine the nature and extent of human error in health care and to introduce some of the lessons that have been learned from experience with other systems and from psychological theory and research on human error.

This chapter must be prefaced with a comment about the perspective from which it was written. It was not written by a health-care professional but by a human-factors practitioner with experience in human error acquired from work in power plants, refineries, aircraft and space vehicles, submarines, and with consumer products. It is practical knowledge learned in trying to develop workable ways to improve the reliability and safety of human-machine systems.


THE CHARACTERISTICS OF SYSTEMS

Despite many differences in function and form, all systems have common characteristics. They involve technology: the tools and machines that serve human needs; systems have an interface: the means or affordances by which users interact with the system; they involve people: in every system but the most highly automated, there are one or more people who operate and maintain it.

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