Last Updated 06 Jul 2020

Human Error Theory in Health Care

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Patient safety is a basic standard of health care. Every step in health care service contains intrinsic unsafe factors . The combination among newest technologies, health innovations and treatments have introduced a synergistic development in health care industry, and transformed it into more complex field. This rise health safety risks which may result from problems in practice, procedures and medicine etc . This Essay will discuss the relationship between human factors and patient safety. Definitions Patient safety is the reduction of unnecessary harm associated with healthcares to acceptable minimum “(Runciman ,Hibbert , Thomson , Der Schaaf , Sherman ,Lewalle , 2009) Human error in health care can be observed by two different methods: “the person approach and the system approach”, each model has own perspectives . Understanding these differences has a significant practical outcomes in healthcare industry and open sights for management of medical error (Reason, 2000). The person approach stress on the hazardous act and procedural deviations of nurses, physicians, pharmacists.

It analyses these risky acts as resulting mainly from deviant mental functions such as lack of memory & concentration , poor enthusiasm , carelessness, , and recklessness(Reason, 2000) . The associated preventive measures are intended mainly at decreasing risky inconsistency in human performance (Reason, 2000) . Whereas the system approach insight human errors as consequences rather than causes, thus it relays the reasons for error occurrence on failure of organizational system (Reason, 2000).

Countermeasures are established on the theory that although “we cannot change the human condition, we can adjust the circumstances under which humans work” (Reason, 2000). Human error Theory Patients always expect miraculous solutions to each problem. In such expectations people who receive medical services tend to believe that no mistakes can happen. It is actually not so, and it is seen that there are instances where the medical errors can occur at any stage (Moyen, Camrie, Stelfox, 2008).

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They can take place if the healthcare provider chooses an inappropriate method of diagnosing the problem. There is another scope for medical error if the execution part goes wrong, even after choosing the correct method. Therefore, such medical errors are only referred to as the human errors in the area of health science (Moyen , Camrie ,Stelfox ,2008 ) . The importance of this issue can be seen according to the report provided by the American Institute of Medicine.

It stated that US Hospitals been have astonishing as there had been deaths which were be ‘avoidable’. Some cases were the medical staff inconvenient, and others were seen that the poor system was actually beyond the failure. The possible flaws in the system are there like the poor communication, between the medical team and between them and the patients; also the reporting system of the hospital suffers from the lack of the coordination in the hospital system (Taxis & Barber, 2003). .

This subject can be better understood with relation to the existing human error theory which consider errors are opportunities for improvement and it interestingly highlight the concept of error, the same issue was adhered by literary thinker and philosopher Francis Bacon(1620), that human mind has always thought of the ‘over-generalisations’ which means that the human mind always have that over-confident element of remembering things. This thought itself gives rise to error, because it all of being thoroughly perfect which is not possible.

The theory stands widely accepted by the British Department of Health, they have moved away from solely blaming the individuals, towards accepting the fact that error is something inevitable ( Runciman ,Hibbert , Thomson , Der Schaaf , Sherman ,Lewalle , 2009) Various literary scholars, scientists and the psychologist have pointed out the fact that there are some cognitive processes and the multiple disturbing factors in the organisational environment and the surroundings that can lead to various accidents in the health care domain.

According to Reason’s interpretation for the concept of error (1990), it is “the failure of a planned action to be completed as intended – without the intervention of some unforeseeable event; or the use of a wrong plan to achieve an aim. ” This definition was somehow subjected to varied reactions, while some accepted this possibility of the error while others thought it was only a pretext for the mistakes done in a medical scenario.

Though in the contemporary context this Human Error Theory has gained popularity because the same has been highly in relevance to the Norman’s idea of error, and thus these perspectives which have been built are the ‘Human Factors’ (Carayon, 2008) Further many factors have been analysed with relation to the same theory like the slips and the lapses from the memory, the mental performance etc (Carayon, 2008). The same theory is widely accepted because of the precise description for the human factors but still the same remains vulnerable to the criticism.

The same effectively brings out that the nursing is an important factor in healthcare but there can be chances for human fallibility where even the same system can fail to acknowledge those how such errors can be avoided. But the critique of the same has been there on building up the counter-argument that the job of nursing accompanies humanities, therefore the basic human factors which can be controlled like the personal hygiene like the wearing of the uniform, washing the hands, the use of anti-bacterial and the anti-viral techniques while handling the patients can guarantee high infection control (Handler, et al, 2006).

The availability of the trained staff which is willing to attend the patients can effectively led to stop the fostering of the errors. Other human factors which can be worked upon by the nursing staff in the hospital can range from the valid reason for which a drug is being used the collection of the true and the right records therefore the proper documentation of the patient’s disease.

These were the critiques that were made on the various human actors which can lead to serious medical flaws (system) and the consequences can become fatal (Handler, et al, 2006). Swiss cheese Model Also, the assessment of the Swiss Cheese Model is necessary to understand that how the system of the medical errors contains the holes of the errors. Alike the holes that are present in a Swiss cheese there are the inherent holes that are present in the medical system.

This interpretation of the errors is formed on the basis of the Swiss cheese model, it emphasis on the causes present in the system rather than blaming any sort of the individual failures. In a way this model has acted so far as a representative for giving an idea how can the painful events occur in a healthcare system and how should they be prevented. The Swiss Cheese Model effectively brings the significant human factors and the system factors which impact the health care set up and the various quality and the safety perspectives.

The medical errors according to the model have a scope to arise because of the Organisational factors, the unsafe work conditions, the human tendency for the unsafe actions and the unsafe acts. The organisational influences are the lack of the management of the resources that are provided in the healthcare settings like the excessive use of the tools which are torn out, the improperly maintained machines and the lack of coordination among the staff members (Reason, 2000).

The next is the distracting and the fluctuating work environment of the hospital, also referred to as the Organisational climate, like the lazy staff members, the inexpert doctors and the dogmatic nurses who are unwilling to attend to the patient’s queries. The third influential factor is the operational process; this accounts to the methodology that is followed for diagnosis, the nurse or the medical supervisor might indulge either too fast processing or the too slow processes (Karman, L. , 2008).

The extreme behaviour of the clinicians and the health care staff thus can be referred to as the problematic in the operational process. The interpretation of the model defines that the healthcare system should be diligent in dealing with the patients at the right time and with the right networking, for this the recommended system by the Swiss Cheese Model where the holes should be seen as the chances where the on-going plan or the operation can fail and the slices of the cheese are the ‘defensive layers’ thus becoming the safety steps or the shields (Karmen, L. 2008).. Therefore, the different layers only act as the filter, where even if the mistake, the error or the flaw in the operation has occurred in the first step then the same can be trapped in the defensive layer, leaving no scope for the error to be passed on to the next level. This is possible because the next layer would not be having the same positions of the holes as it was in the previous layer.

This interpretation thus propagates the main idea that though the natural tendency of a human being to make mistakes cannot be corrected but the correction can be made at the part of the plan that is being executed so that the chances of the fatal consequences are effectively minimised (Karmen, L. , 2008). Conclusion On the basis of the Human Error Theory and the basic Human Factors that are responsible for the failure of the health care system, one can conclude that the critical review of Swiss Cheese Model can come to rescue many patients ho are admitted to the healthcare centres. The question which the analysis has answered is that ‘Can the human errors be effectively reduced in the medical context? ’ and it seems that a positive light spot on the solutions to catch the problematic have been provided by the collaborative efforts of the literary precursors, the medical scholars and the psychologists. The model and the theory which has been studied effectively solves the problem by attacking its root in that health care setting is an indefinite system in which the safety of the patient resides (Wagner, C et. l , 2001). The safety & quality is only achieved while there is possible healthy interaction between the medical providers, the health care standards and the potential errors in the existing health care system. References Carayon, P. (2010). Human factors in patient safety as an innovation. Applied Ergonomics, 41(5): 657-665. Handler,S. , Castle, N. , Studenski, S. , Perera, S. , Fridsma, D. , Nace, D. , & Hanlon, J. (2006). Patient safety culture assessment in the nursing home.

Qual Saf Health Care 15(6), 400-404. Karmen, L. (2008). Pilot, Swiss cheese, and cash machinery: Health of the Health System. Croatian Medical Journal, 49(5), 689. Moyen, E. , Camire, E. , & Stelfox, H. T. (2008). Clinical review: medication errors in critical care. Critical Care Medicine, 12(2), 208. Taxis, K. , & Barber, N. (2003). Ethnographic study of incidence and severity of intravenous drug errors. British Medical Journal, 11, 326. Reason, J. (2000).

Human error: models and management. British Medical Journal, 320:768-70. Runciman, W. , Hibbert,P. , Thomson, R. , Schaaf, T. V. D. , Sherman, H. , & Lewalle, P. (2009). Towards an international classification for patient safety: key concepts and terms. International Journal for Quality in Health Care, 21(1). 18-26. Wagner, C. , Wal, G. , Groenewegen, P. , & Bakker, D. (2001). The effectiveness of quality systems in nursing homes: a review. Qual Health Care 10(4), 211-217. .

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