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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
Journal of Patient Safety
|December 2, 2011
Summary
Human cognitive processes, like automode processing and skill-based errors, contribute to wrong procedures in healthcare. Addressing these cognitive factors in system fixes offers better safety outcomes than traditional disciplinary actions.
Area of Science:
- Healthcare safety research
- Cognitive psychology in medicine
Background:
- Wrong procedures pose significant risks in healthcare settings.
- Understanding the human factors contributing to errors is crucial for improving patient safety.
Purpose of the Study:
- To explore the role of human behaviors and cognitive processes in medical errors.
- To analyze case studies of wrong procedures through the lens of human error theory.
Main Methods:
- Case analysis of five wrong procedures.
- Application of James Reason's human error theory.
Main Results:
- Cognitive underspecification, cognitive flips, automode processing, and skill-based errors were identified as contributors.
- Wrong-site procedures were the most frequent type of error.
- Supervisory actions often focused on individual performance, neglecting cognitive elements.
Conclusions:
- System-level interventions based on human cognition principles are more effective for sustained safety.
- Traditional approaches like counseling and disciplinary actions are less effective than cognitive-focused system fixes.
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