Author: Marilyn Sue Bogner (ed)
This book is a collaborative work which captures the varied facets of human error. It succeeds because of the strong contributions of patient safety leaders such as Lucian Leape and David Gaba. The foreword by James Reason sets the pace with a discussion of the main types of human errors; active errors committed by ‘the fallible individuals at the sharp end’, and latent errors resulting from decisions taken in the upper echelons’ (page xi). He argued that the best strategy to address human error is to ‘drain the swamp‘ of latent errors because these are ‘…more amenable to diagnosis and remediation…’ (pages xiii-xiv). He also criticised the ‘universal, natural, emotionally satisfying, and …convenient’ tendency to blame individuals when things go wrong even though this ‘has little or no remedial value’ (page ix).
In establishing the scale of human error in medicine, Lucian Leape said ‘each encounter, indeed each treatment or diagnostic maneuver, presents an opportunity for error‘ (page 13). Using very helpful tables and figures, he explored different types of human error such as technical complications and diagnostic mishaps (pages 21). He also discussed strategies to prevent medical mistakes such as depersonalizing errors (page 23).
Neville Moray illustrated the close relationship between the human and the system, saying ‘… human error is not only a property of humans-it is a property of systems that include humans…'(page 90). He covered a wide spectrum of subjects such as team behaviour, physical ergonomics, organisational constraints, hierarchical systems, and corporate policies (pages 76-80).
Harold Van Cott, in his discourse on the causes of human error, referred to the ‘human microcatastrophes‘ that occur throughout the health care system (page 56). He reviewed the contribution of rapidly advancing technology and economic constraints to medical mistakes, and emphasised the importance of ‘root causes’ in error management (pages 55-61).
Thomas B. Sheridan and James C. Thompson also looked at the contribution of technology to human error. Their commentary focussed on the positive influence of computer-based and robotic systems such as telediagnosis and telesurgery (pages 145-150). J.W. Sanders discussed the effect of medical devices on human error, asserting that medical error is often the consequence of poor engineering. He advised medical equipment designers to make their devices safer by understanding human psychology (pages 159).
Many chapters explored the human factors that operate at the sharp end. Richard Cook and David Woods, for example, explained how mental models, cognitive fixation, and goal conflicts may lead to mistakes (page 262-280). Gerald Krueger gives an account of the effect of fatigue on performance with reference to reaction time, problem solving, and motivation (page 312-313). Georgine Vroman, Ilene Cihen, and Nancy Volkman reviewed the impact of cognitive errors on the doctor-patient interaction.
The book covers many other topics such as therapeutic misadventure (page 29); statistical training in medical education (page 123); calibration of knowledge (page 264); and cognitive biases such as the representativeness and availability heuristics (page 134-135).
This book addresses the broad and important topic of human factors, exploring the relative contributions of the individual and the system. The content is easily accessible to all physicians although academics and human factors specialists would appreciate it better. Although the book was published more than two decades ago, the subjects it addresses remain relevant today. There is an overlap of contents across the chapters but this is probably inevitable with a multi-author book such as this.
The book is a significant contribution to human factors and it covers the topic exhaustively. It is rather dated, and the references old, but its lessons are still relevant. I recommend it.
- Publisher, place, date: Lawrence Erlbaum Associates, Hove, 1994
- Number of chapters: 18
- Pages: 411
- ISBN: 9780805813869
- Price: £50.99
- Star rating: 4 stars