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The reasons behind human error

Staff Development Weekly: Insight on Evidence-Based Practice in Education, January 17, 2008

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In the old school of human error research, it was believed that human error is a cause of accidents and incidents. Investigators would focus on the people involved and seek to explain the failure. This focus led to interrogations that focused on the inaccurate assessments made by those involved. As a result, the investigators made bad judgments (which led to wrong decisions).

New research tries to understand why people make the decisions they do by understanding deeper problems in the organizational systems. When undesirable outcomes occur, there is usually a poor decision made somewhere in the error chain. We must believe that the person who made the poor decision did not intend the outcome. Human error is not random. We can trace decision-making patterns and trends to previous behavior. Human error is not the ending point of the analysis; it is the starting point. Rule-based errors typically occur for one of three reasons:

1. The rule itself was not correct, and we followed it
2. The rule was not correct; therefore, we applied it incorrectly
3. The rule and the information regarding it were correct; we had a problem complying with it

To get more information, go to Briefings on Patient Safety (BOPS). For the cost of just three stories, you can get the entire January issue of BOPS. Click here to choose between the PDF and HTML versions for just $30. Subscribers to the online version of BOPS have free access to this article. Subscribers to the print newsletter can find this article in their January issue.

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