Man versus System

In human error, Normal Accident Theory, Patient Safety, Safety climate on November 5, 2010 at 10:20 am

The person approach to looking at safety issues assumes failures are the result of the individual(s) involved in direct patient contact.  In this model, when something goes wrong it is the provider’s fault due to a knowledge deficit, not paying attention (and other cognitive processes), or not at their best (St. Pierre, et al., 2008).  Some other descriptions assumed of  individuals involved in a person approach to failures include: forgetful, unmotivated, negligence, lazy, stupid, reckless…click below to read more

Solutions in this type of blame the person process would therefore stem from the aforementioned assumptions.  Common types of follow up include training; “motivation” statements such as “be more careful, pay more attention, concentrate; more rules and policies; disciplinary actions and even the threat of criminal charges and litigation.  While this approach may seem convenient for an organization or prudent in a situation where morality may seem to dictate response,  this isolates the failure from the system from which it came.  This response is faulty in that the same set of circumstances could lead another provider down the same path of failure.  In fact in many analyses from high stakes environments, often the best people make the worst mistakes (St. Pierre, et al., 2008).

Some other side effects of a person approach process may include employees hiding errors, bullying, and energy being directed towards self preservation instead of meeting organizational goals. The person approach may actually exacerbate unsafe conditions.

An alternate approach is a systems approach. Instead of looking for the one person at the sharp end of the process, many aspects up to the blunt end are examined for contributing factors (St Pierre, et al., 2008). This fits with normal accident theory and the concept that errors are to be expected. This approach understands that failures are the result of an interaction between normal cognitive processes and system complexities. Complexity changes the conditions under which humans work (St. Pierre, et al., 2008).

Solutions in this type of approach shy away from looking at who is to blame. Instead the question becomes “what exactly went wrong?”
Descriptions in this approach include: execution vs planning failure,
active errors vs latent errors, and communication and teamwork failures.

Moving an organization away from a culture of blame and accusation is necessary for safety. Transparency, justice and honesty are necessary to create a safety culture. Any high stakes organization should focus on increasing safety by giving the sharp end employees the tools to manage and prevent failures. These tools must be simple and applicable in many situations. Rules and policies don’t always accomplish this and sometimes contribute to complexity.

“Rules are a monument to human failure” (Haskins, 2010).
The military trains in a system called Outcomes-based training. In this training the desired outcome is defined but the trainees are allowed the freedom to come to this outcome in different ways. There are boundaries and simple guidelines initiated by a commander, however this concept of training promotes initiative and innovation. Perhaps this is the route to safety in hospitals rather than training on complex detailed policies or procedures.

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