Underlying Patterns

In Patient Safety on March 4, 2011 at 1:26 pm

When errors or near misses occur they may look very different on the surface. Research in human factors however has determined that there are many similar patterns in errors that involve human-system interaction.

Some of the common patterns are (Carayon, 2007):

  • Trying to solve a problem with only one point of view or hypothesis
  • Missing the side effects of a plan or change
  • Hindsight bias from knowing the outcome before looking back on the contributory events
  • Front line employees have difficulty applying standards to a changing situation when they do not have a true understanding of the intent of the standards
  • Alarm overload or false alarms leading to missed or ignored warnings with machines but also conversations and interactions
  • Errors in technology devices that do not have good feedback systems.  Good feedback systems keep the operator informed as to where they are in a process or if an action has been completed.

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