We report on our observations in the operating room, where we examined the work activity in hopes of understanding why human errors can occur even with simple tasks (e.g., loading a syringe with the wrong solution). We employed a human factors analysis guided by our understanding of human cognition (memory, attention, action planning, etc.) with the goal of improving safety. By applying psychological theory (human cognition) to this real-world environment, we suggest where human error is prone to occur due to factors such as non-optimal procedures and design layout. We speculate that such weaknesses can contribute to adverse events and offer low-cost solutions aimed at minimizing the likelihood of such errors occurring.
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References
1.
AllnuttM. F. (1987). Human factors in accidents. British Journal of Anaesthesia, 59, 856–864.
2.
BrennanT. A.LeapeL. L.LairdN. M.HerbertL.LocalioA. R.LawthersA. G.NewhouseJ. P.WeilerP. C.HiattH. H. (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324 (6), 370–284.
3.
BognerM. S. (1994). Human error in medicine: A frontier for change. In BognerM. S., Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, pp. 373–383.
4.
ChopraV.BovillJ. G.SpierdijkJ.KoornneefF. (1992). Reported significant observations during anaesthesia: A prospective analysis over an 18-month period. British Journal of Anaesthesia, 68, 13–17.
5.
CookR. I.WoodsD. D. (1994). Operating at the sharp end. In BognerM. S., Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, pp. 255–310.
6.
CooperJ. B.NewbowerR. S.KiteR. J. (1984). An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology, 60, 34–42.
7.
CraigJ.WilsonM. E. (1981). A survey of anaesthetic misadventures. Anaesthesia, 36, 933–936.
8.
CurrieM. (1989). A prospective survey of anaesthetic critical events in a teaching hospital. Anaesthesia Intensive Care, 17, 403–411.
9.
CurrieM.MackayP.MorganC.RuncimanW. B.RussellW. J.SellenA.WebbR. K.WilliamsonJ. A. (1993). The “wrong drug” problem in anaesthesia: An analysis of 2000 incident reports. Anaesthesia Intensive Care, 21, 596–601.
10.
GabaD. M. (1994). Human error in dynamic medical domains. In BognerM. S., Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, pp. 197–224.
11.
GladstoneJ. (1995). Drug administration errors: A study into the factors underlying the occurrence and reporting of drug errors in a district general hospital. Journal of Advanced Nursing, 22, 628–637.
12.
KohnL. T.CorriganJ. M.DonaldsonM. S., (2000). To err is human: Building a safer health system. Washington, D. C: National Academy Press.
13.
KumarV.BarcellosW. A.MehtaM. P.CarterJ. G. (1988). An analysis of critical incidents in a teaching department for quality assurance: A survey of mishaps during anaesthesia. Anaesthesia, 43, 879–883.
14.
LeapeL. L. (1994). Error in medicine. Journal of the American Medical Association (JAMA), 272 (23), 1851–1857.
15.
NormanD. A. (1981). Categorization of action slips. Psychological Review, 88 (1), 1–15.
16.
NormanD. A. (1988). The Psychology of Everyday Things. New York: Basic Books.
17.
OrserB. A.OxornD. C. (1994). An Anaesthetic drug error: Minimizing the risk. Canadian Journal of Anaesthesia, 41 (2), 120–124.
18.
PashlerH. E.The Psychology of Attention. Cambridge, MA: MIT Press.
19.
ReasonJ. (1984). Lapses of attention in everyday life. In ParasuramanR.DaviesD. R., Varieties of Attention. Orlando, Fla: Academic Press, pp. 515–549.
20.
ReasonJ. (1990). Human Error. Cambridge: Cambridge University Press.
21.
SklarA. E.SarterN. B. (1999). Good vibrations: Tactile feedback in support of attention allocation and human-automation coordination in event-driven domains. Human Factors, 41, (4), 543–53.
22.
Van CottH. (1994). Human errors: Their causes and reduction. In BognerM. S., Human error in medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, pp. 53–65.
23.
WilliamsonJ. A.WebbR. K.SellenA.RuncimanW. B.Van Der WaltJ. H. (1993). Human failure: An analysis of 2000 incident reports. Anaesthesia Intensive Care, 21, 678–683.
