The science of human error

What is human error?

Human error is inescapable simply because we are human. Human error is an act that is not intended, may happen at random, and may not be fully preventable. Some words that may be used to describe human error include but are not limited to inadvertent, slip, lapse, mistake, or accident. The outcome that results from human error is usually undesirable and sometimes outside of acceptable limits. Most importantly, true human error is a deviation from intention.

There are various definitions of human error that share a common theme—an unintended act. And there are many different types of errors described: errors of omission (not doing something that should be done), errors of commission (doing the wrong thing), technical errors (failure related to human–technical interface), organizational errors (system set-ups), and near-miss errors which don't reach the patient but could cause harm if they did. However, understanding human error may simply be acknowledging and accepting that humans are not perfect. Humans are fallible and a part of a sociological existence. We may even argue that there is no science to human error. Human error may be a part of social work.

Human error has earned the spotlight in healthcare for 2 decades now. It was in 1999 when the Institute of Medicine (IOM), now known as the National Academy of Medicine (NAM), released “To Err is Human,” a publication that identified as many as 98,000 patient deaths resulted from medical error in the United States. Since this initial effort to understand the magnitude of medical error, more recent studies conclude that much larger proportions of patient death and harm result from error. Medical error may be the third leading cause of death in the United States.

Human error and healthcare

Healthcare meets the definition criteria as a complex system for humans to work in, composed of “many interacting parts where it is difficult, if not impossible, to predict the behavior of the system based on knowledge of its component parts.” The demanding macrosystem (container that holds micro- and mesosystems together) of healthcare is made up of microsystems (smallest part of the system that provides care to the patient (i.e., a clinical unit)) and a variety of mesosystems (glue linking microsystems) which contribute to the care and safety of our patients and families). When estimating the number of staff involved in one patient's care for one shift, it seems that there can be various numbers at each microsystem.

Microsystems involved to care for one acutely ill patient in one 12 hour shift:

Microsystem 1: Pharmacy (technicians and pharmacists).

Microsystem 2: Blood bank (technicians, nurses, and doctors).

Microsystem 3: Radiology (techs and doctors).

Microsystem 4: Emergency department (techs, nurses, and doctors).

Microsystem 5: ICU (nurses and doctors).

Since our complex systems are not perfected and to err is human, medical error has been of great concern. Data clearly show that the healthcare system has grown to be more complex, with more acute patient needs and slim resources requiring nationwide efforts to improve patient safety and to implement safer systems within healthcare. With a lack of highly reliable principles in place on a consistent basis, our healthcare system will continue to allow human error.

Person approach versus the system approach

Contributing factors to human error include but are not limited to stress, fatigue, hunger, emotional state, communication, teamwork, leadership, situational awareness or lack thereof, etc. Given the complex nature of healthcare, it is no wonder these factors play a significant role in the healthcare system.

Once error is identified, there are two approaches to understanding the nature of how the error occurred: first, the person approach where the organization typically blames the individual for the error. Cases such as Eric Cropp, PharmD, and Kimberly Hiatt, RN, are examples where people were blamed for mistakes that occurred under their watch. The person approach might suggest the healthcare provider was careless, negligent, or inattentive. Unfortunately, the healthcare provider likely suffers consequences that impact them personally and professionally, such as in the two cases mentioned above. The impact of the person approach may not be a system that is safer, rather a relief on the organizations' responsibility for patient safety and a punitive culture.