Human Error in Medicine

By Marilyn Sue Bogner | Go to book overview

13
Operating at the Sharp End: The Complexity of Human Error

Richard I. Cook and David D. Woods The Ohio State University

Studies of incidents in medicine and other fields attribute most bad outcomes to a category of human performance labeled human error. For example, surveys of anesthetic incidents in the operating room have attributed between 70% and 82% of the incidents surveyed to the human element ( Chopra, Bovill, Spierdijk, & Koornneef, 1992; Cooper, Newbower, Long, & McPeek, 1978). Similar surveys in aviation have attributed more than 70% of incidents to crew error ( Boeing Product Safety Organization, 1993). In general, incident surveys in a variety of industries attribute similar percentages of critical events to human error (for example, see Hollnagel, 1993, Table 1). The result is the perception, in both professional and lay communities, of a "human error problem" in medicine, aviation, nuclear power generation, and similar domains. To cope with this perceived unreliability of people, it is conventional to try to reduce or regiment the human's role in a risky system by enforcing standard practices and work rules and by using automation to shift activity away from people.

Generally, the "human" referred to when an incident is ascribed to human error is some individual or team of practitioners who work at what Reason calls the "sharp end" of the system (Reason, 1990; Fig. 13.1). Practitioners at the sharp end actually interact with the hazardous process in their roles as pilots, physicians, spacecraft controllers, or power plant operators. In medicine, these practitioners are anesthesiologists, surgeons, nurses, and some technicians who are physically and temporally close to the patient. Those at the "blunt end" of the system, to continue Reason's analogy, affect safety through their effect on the constraints and resources acting on the practitioners at the sharp end. The blunt end includes the managers, system

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