MAKinG MiStAKeS
learning
What human
factors can lead
to mistakes?
from mistakes
■ fatigue (sleep
deprivation)
■ Hunger – long lapses
between food/drink
■ lack of concentration
to err is human unless you are a doctor, is the view ■ interruptions
■ distractions
held by some, but Julie Wilson argues that all doctors ■ lack of training
■ lack of information
make mistakes and the key is to learn from them ■ unfamiliar with place
of work (different
room, new ward, etc)
a
sk yourself: “Have into a diesel-fuelled car? and mistakes rarely are.” ■ other – illness, under
you made any if yes, then you are not His sentiments are echoed influence of drugs,
mistakes today?” if alone. in 2006 more than in the work of renowned alcohol, etc
your immediate thoughts 120,000 people called out cognitive psychologist and
are along the lines of: “of a breakdown service after expert on error dr James
course not. i’m a good gp filling up their cars with the reason. He began to explore contact with the patient or
and have completed years wrong type of fuel. even human error after he put system. they take a variety
of training; mistakes are Wayne rooney had to be cat food in his teapot, while of forms: slips, lapses,
caused by carelessness, not rescued on the motorway making tea and feeding his fumbles, mistakes, and
by good gps”, then read on. when he put the wrong cat. the two components procedural violations.
no-one is a perfect gp; fuel in colleen’s range got mixed up; both the ■ latent conditions arise
mistakes don’t just happen rover, and the mistake cost teapot and the cat’s feeding from decisions made by
in our everyday lives, they him more than £6,000. dish afforded the same management, etc, and
can happen at work. if a opportunity – putting stuff in. these decisions have the
plumber put a nail through So why do we make dr reason created potential for introducing
a pipe, it would cause a these errors? the “swiss cheese” failure into the system.
mess, but no-one would according to Mike o’leary model to explain human for example, these
die. However, if a gp makes ex-chief executive of British fallibility, which is made include time pressure,
a mistake, it could result airways: “accidents rarely up of two approaches: understaffing and
in serious complications. happen without warning. the active (person) and inadequate training.
so think again: “Have you the sequence of failure the latent (system). the “swiss cheese” model
made a mistake recently and mistakes that cause an ■ active failures are the illustrates the trajectory of
in your everyday life?” accident may be unique, but unsafe acts committed by an accident. the holes in
ever put unleaded petrol the individual failures people who are in direct the swiss cheese represent
the failures in the system’s
James reason’s famous “Swiss cheese”: defences that allow a
successive layers of defences, barriers and safeguards. hazard to pass through. so
error is a combination of
some holes are due to active failures human and system failures.
even the best of us make
mistakes, so it is important
that defences are in place to
make these mistakes due to
human fallibility less likely.
Scenario
vials of lasix and potassium
chloride are stored in
containers next to each
other in a treatment
other holes due to latent failures room. a patient goes into
(resident “pathogens”) congestive cardiac failure.
the doctor rushes into the
treatment room to obtain a
24 sessional gp | voluMe 1 | 2009 www.mps.org.uk
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