HUMAN ERROR

Human Error and its Prevention

Human Error and its Prevention

Human Error

The situation or condition of being wrong in behavior or judgment called human error (Reason, 1990). The term human error is used by us frequently. We think that whenever we use this term, everyone knows that what it means. For this problem, without a definition we may not get the exact understanding of the term and often get misunderstanding. The basic semantic dilemma is that the term has three meanings: It can stand for the root of something, the incident itself (the action), or the result of the action. The meanings discussed below:

Human Error as Cause

A patient's harsh response can be due to a nurse overseeing a medication from which the patient is allergic (Senders, 1991).

Human Error as Event

A doctor fails to remember to match the patient's history while taking decision. In this situation, the result of this may not be considered. The crucial element here is the event of the error (Senders, 1991).

Human Error as Consequence

A doctor forgets a sponge or tool inside a patient after operation. Then, outcome of this error is most important then its occurrence (Senders, 1991).

Discussion

Human error is divided into two broad categories.

Errors of Omission

It is an error in which a person fails in performing a task or performing it in a given time. It means that something that should be done could not be done either it was skipped or did not perform well (Dekker, 2006).

Errors of Commission

It is an error in which a person performs a wrong action or performs a right action in a wrong way. Either action performed or not, but its result falls in an error category. Both errors of omission and commission explain a failure to attain set results in a way that action was not performed or not according to set standards. It includes both actions that are unintentionally done and intentionally (Dekker, 2006).

To put things into framework, there are three main stages of cognition (planning, storage, and execution), which have link with three error types (mistakes, slips, and lapses), which are in detail below:

Mistakes

Mistakes happen when a set result is not achieved still there was perfection in the plan. It is typically a situation in which the original plan was not correct, and its implementation resulted in an unwanted result (Dekker, 2006).

Suppose, a hospital acquires a new type of oxygen pump from a new manufacturer, but the nurse is not present for the in-service instruction of the new procedures that how to make use of the pump. The nurse starts her shift and is locate in a position to use that new pump. Using her previous experience she operates the new pump using the old procedure. As an effect, a patient is overdosed and falls into a coma (Dekker, 2006).

Lapses

Lapses are connected with our memories. These are usually not noticeable events.

Slips

Slips are normally externalized, noticeable events that are not in accordance with a procedure. Slips are normally linked with the execution stage of cognition (Dekker, ...