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Application of human error theory in case analysis of wrong procedures
1New York University College of Nursing, New York, New York, USA. duthie01@nyu.edu
Objectives:
The goal of this study was to contribute to the emerging body of literature about the role of human behaviors and cognitive processes in the commission of wrong procedures.
Methods:
Case analysis of 5 wrong procedures in operative and nonoperative settings using James Reason's human error theory was performed.
Results:
The case analysis showed that cognitive underspecification, cognitive flips, automode processing, and skill-based errors were contributory to wrong procedures. Wrong-site procedures accounted for the preponderance of the cases. Front-line supervisory staff used corrective actions that focused on the performance of the individual without taking into account cognitive factors.
Conclusions:
System fixes using human cognition concepts have a greater chance of achieving sustainable safety outcomes than those that are based on the traditional approach of counseling, education, and disciplinary action for staff.
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