Editorials

Human error, particularly in the practice of medicine, is inescapable and ubiquitous. Error occurs when a planned activity fails to produce its planned outcome, and when the failure is not due to chance. The era of the submissive patient who blindly accepts the opinion and actions of the medical professional is long gone. The information era and the ease of access to information via libraries and the internet have enabled our patients to research our opinions and criticise our actions. Moreover, patients develop expectations of outcome. All this scrutiny of medical professional conduct is further fuelled by the legal profession and media instilling a sense of victimisation and “angst” in the public. Human error can be viewed in two ways: the person approach and the system approach. The person approach focuses on unsafe and erroneous acts by the individual at “the coal-face”, and allows for the attribution of blame and the meeting out of punishment. This approach views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence and recklessness. Countermeasures are mounted mainly at reducing unwanted variability in human behaviour. These measures include poster campaigns that appeal to people’s sense of fear, writing or amending yet another protocol, disciplinary measures, threats of litigation, retraining, naming, blaming and shaming. Blaming individuals, especially if you are the victim of error, is emotionally more satisfying than targeting institutions. Followers of this approach tend to treat errors as moral issues, assuming that “bad things happen to bad people”. This model is a relatively primitive and often counterproductive approach and may be seen as bullying or be interpreted as harassment. Seeking to uncouple a person’s unsafe acts from any institutional responsibility is obviously in the interest of administrators. The system approach works on the premise that humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors. These include recurrent error traps in the workplace and the organisational processes that give rise to them. Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work. A central idea is that of system defences. All hazardous technologies possess barriers and safeguards. When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed (the analogy of lining up the holes in slices of Swiss cheese is often referred to). The system approach is subdivided into active failures and latent failures. Active failures are unsafe actions by people in contact with the patient and due to lack of education or skills (or both). Protocolisation and simplification of activities have been employed to attempt to reduce active failures. “Everything should be made as simple as possible, but not simpler.” Albert Einstein. The other subdivision of the system approach is that of latent failures, which can best been described as resident factors in a system that may predispose to a set of unfavourable conditions culminating in an error (e.g. fatigue due to understaffing and poor rostering, inappropriately difficult casemix for the attending physician, progressive erosion of safety nets by poor maintenance of equipment, outdated equipment, workplace design inefficiencies or inappropriate alarm settings). Williamson et al, reported a blood transfusion error that occurred after seven pairs of medical staff had checked the correctness of the procedure. Donchin et al, conducted a study to investigate the nature and causes of human errors in the intensive care unit (ICU). A human error was defined as a deviation from standard conduct, as well as addition or omission of actions relating to standard operational instructions or routines of the unit. During 4 months of data collection, a total of 554 human errors were reported. There was an average of 178 activities per patient per day and an estimated number of 1.7 errors per patient per day. The 1.7 errors per day indicate that hospital personnel were functioning at a 99% level of proficiency. However, a 1% failure rate is substantially higher than is tolerated in industry, particularly in hazardous fields such as aviation and nuclear power. Even 99.9% proficiency may not be good enough. If we had to live with 99.9% proficiency, this implies two unsafe plane landings per day at O’Hare airport, Chicago; 16 000 pieces of lost mail every hour and 32 000 bank cheques deducted from the wrong bank account every hour in the United States of America. In the Donchin et al study, for the ICU as a whole, a severe or potentially detrimental error occurred on average twice a day. Physicians and nurses were approximately equal contributors to the number of errors, although nurses performed 84% of the activities.