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Human error: models and management

2000; BMJ; Volume: 172; Issue: 6 Linguagem: Inglês

10.1136/ewjm.172.6.393

1476-2978

J. Reason,

Risk and Safety Analysis

Human error: models and managementThe problem of human error can be viewed in 2 ways: the person approach and the system approach.Each has its model of error causation, and each model gives rise to different philosophies of error management.Understanding these differences has important practical implications for coping with the ever-present risk of mishaps in clinical practice. PERSON APPROACHThe long-standing and widespread tradition of the person approach focuses on the unsafe acts-errors and procedural violations-of people on the front line: nurses, physicians, surgeons, anesthetists, pharmacists, and the like.It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.The associated countermeasures are directed mainly at reducing unwanted variability in human behavior.These methods include poster campaigns that appeal to people's fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming.Followers of these approaches tend to treat errors as moral issues, assuming that bad things happen to bad people-what psychologists have called the "just-world hypothesis." 1 SYSTEM APPROACHThe basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organizations.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 organizational processes that give rise to them.Countermeasures are based on the assumption that althoughThe Swiss cheese model of how defenses, barriers, and safeguards may be penetrated by an accident trajectory Summary points• The problem of human fallibility has 2 approaches: the person and the system• The person approach focuses on the errors of individuals: forgetfulness, inattention, or moral weakness• The system approach concentrates on the conditions under which people work and tries to build defenses to avert errors or mitigate their effects• High-reliability organizations, which have fewer accidents, recognize that human variability is the approach to averting errors, but they work hard to focus that variability and are preoccupied with the possibility of failure .......