Overview
Definitions of Error
Basic Tenets of Human Error
Human Factors Engineering
Human Performance
Vocabulary
Types of Errors
Systems to Reduce Errors
Stroop Test
Swiss Cheese Model
Toxic Cascades
Lessons from Other Industries
Basic Safety Principles
Summary

Lessons from Other Industries

Aviation and nuclear power are the industries most frequently studied to understand safety in complex systems. Characteristics:

  • Complex, tightly coupled systems
  • Recognize the importance of human factors
  • Excellent track records for safety
  • Continuously strive to improve safety

Coupled systems are those which are linked and dependent on each other for successful execution.

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Human factors speak to those human characteristics that should be considered in the design of processes.

Human factors engineering is the design of equipment and processes with those human characteristics specifically in mind.

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What lessons can healthcare learn from other industries?

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  • Respect human limits, and design jobs for safety
  • Avoid reliance on memory
  • Use constraints, forcing functions, and natural mappings
  • Simplify and standardize whenever possible
  • Promote effective team functioning
  • Encourage reporting of errors and near-misses, and use them as opportunities to prevent future errors
  • Include the patient in the design of safe processes
  • Anticipate the unplanned
  • Plan for failure, and design for recovery

 

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