Mänskliga fel Säker primärvård Modul 4 – Den mänskliga faktorn

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1 Mänskliga fel Säker primärvård Modul 4 – Den mänskliga faktorn
James Reason Professor Emeritus University of Manchester, Storbritannien Human errors, and the system factors that trigger and shape them, dominate the risks to patient safety. As such they warrant a central place in any account of safety management in health care. The module is in four parts. The first deals with the definition and categorisation of errors. In neither case is there universal agreement, so I’ve focused on the materials that make sense to me. The second part discusses five pervasive myths about human error. The third part deals with error traps. And the concluding section discusses error management.

2 De flesta definitionerna av fel inbegriper någon form av avvikelse
Avvikelsen kan vara från stående (snubbla eller falla) en tänkt avsikt (förbiseende eller miss) en korrekt process (misstag) det önskade resultatet (miss, förbiseende eller misstag) regler och rutiner (överträdelse) There is no one agreed definition of human error, even among the psychologists who study the topic for a living. Some of them reject the notion of error altogether, others object to the term ‘error’, preferring wordy alternatives like ‘human erroneous actions’. We will not get into those muddy waters. Fortunately, the everyday word ‘error’ is something that nearly everyone understands, so we will stick with it and take a commonsense workaday approach to both its definition and the various ways that it can be classified. Almost everyone accepts that an error entails some kind of deviation, although the standard against which the divergence is to be noted can vary. The slide lists a number of these standards and (in parentheses) gives names to the type of error(s) involved. ‘Error’ is the generic term covering all the varieties. Whereas most errors are unintended, a violation usually involves a deliberate departure from the rules, protocol or procedures. Such non-compliances need not be in error, but they often are.

3 En taxonomi baserad på avsikt
Fanns en planerad avsikt med handlingen? nej Ofrivillig händelse (snubbla eller fumla) ja Gick det som planerat? nej Oavsiktlig händelse (miss eller förbiseende) ja Uppnåddes önskat resultat? nej Avsiktlig men felaktig handling The notion of intention is central to a psychological understanding of both the nature and varieties of error. If you were struck down by a chunk of returning space debris, you would not achieve your desired goal, but you could hardly be said to have made an error. The same applies to everyday trips and stumbles—except of course when you were moving recklessly over rough ground when a trip could have been anticipated. The law recognises certain unintentional acts as being non-criminal (for the most part) and calls them ‘automatisms’. At the second level of the tree we have ‘absent-minded’ actions where the plan may have been appropriate but the actions didn’t go as planned. These are slips (actions-not-as-planned) or lapses (memory failures of one kind or another). At the third level, we have mistakes in which the actions went as planned but the plan was inadequate in some respects, (i.e., it failed to chart an effective path towards the desired goal). As we shall see later, mistakes fall into two categories: rule-based mistakes and knowledge-based mistakes. At the fourth level, there is no error since the actions achieved their goal. But this does not rule out the possibility of a violation. A ‘successful’ action meets the actor’s requirements, but these are not necessarily ‘correct’ (i.e., compliant or socially desirable). A successful crime, for example, entails successful actions—but only from the criminal’s viewpoint. ja Båda kan också vara överträdelser Lyckad handling

4 Definitioner baserade på klassifikationer av avsikt
FELET: Planerade handlingar uppnår inte förväntat resultat Det sker missar och förbiseenden i hela eller delar av handlingen Det var fel plan (t.ex. metodval eller situationsuppfattning) This slide offers a working definition of error that is widely used in aviation, nuclear power, chemical process plants and many other hazardous domains. It identifies two ways in which planned actions fail to achieve their desired end: execution failures (slips and lapses) and planning failures (mistakes). Mistakes are further broken down into two categories: Rule-based mistakes—All HC professionals have a very large stock of ‘rules’ (If X do Y) to deal with medical conditions. These rules comprise their expertise. Sometimes, however, one may misapply a good rule because one fails to notice the contra-indications (e.g., treat an infant for ‘flu rather than meningitis), apply a bad rule (everyone has these bad rules in their repertoire: they work well enough most of the time, but they can lead to bad outcomes), or fail to apply a good rule (violation). Knowledge-based mistakes—these occur when one encounters a novel situation and have to work out a problem solution from first principles and ‘on the hoof’. This is highly error provoking. Indeed, we usually only come to a correct solution by trial-and-error learning—you try something, notice what goes wrong, then modify your subsequent behaviour accordingly. This is all very well in a forgiving environment, but hospitals and clinics are not usually so error-tolerant. The various types of rule-based and knowledge-based mistakes are discussed further in the Human Factors Resource Material, as are the varieties of slips and lapses.

5 Att upptäcka och korrigera sina misstag
Erfarna och skickliga medarbetare är inte felfria. Tvärtom – de är förberedda på, upptäcker och kompenserar, när något går snett. Chansen att upptäcka misstaget hänger ihop med vilken typ av misstag som är begånget: Felgrepp Glömska Missförstånd Some recent observations of paediatric cardiothoracic surgeons performing the ‘arterial switch’ procedure revealed something very important. The virtuoso surgeons were not the ones that were error-free—all of them made life-threatening errors. No, the real virtuosi were those surgeons who had trained themselves to expect mistakes and who detected and recovered them successfully (refs). Error detection depends on the criterion against which the current performance is judged. Trips and stumbles are the easiest to detect and correct because we have hard-wired postural reflexes that do it automatically. Slips and lapses are also relatively easy to detect because we mostly know what our current intentions are and can spot the deviation—as when we get into the bath with our socks on, or say ‘thank you’ to a coffee machine. Mistakes, however, are much harder to detect and correct because we don’t always know what the ideal or correct path to our goal is. And even after the event, mistakes often remain a matter of judgement. Was it a mistake, for example, to intervene militarily in Iraq? Many people are convinced that it was, but only history will yield the final answer—and even then the historians will argue about it. Ökande svårighet för upptäckt

6 Fem myter om fel Fel är per definition av ondo.
Dåliga människor gör hemska fel. Fel inträffar slumpmässigt och varierat. Fel begås sällan av yrkesmänniskor, men när det händer kan de orsaka skada. Det är lättare att ändra på människor än på situationer. Amongst the greatest obstacles to effective error management are the pervasive myths regarding the nature of human error. As mentioned earlier, all of them contain some grain of truth—otherwise they would not be so persistent. But what may serve us well in everyday activities can be a serious problem when it comes to planning and implementing error management programme. Here we’ll consider five myths—there are many more, but these are probably the most obstructive.

7 Misstag är i sig inte av ondo
Att göra misstag är ett sätt för människor att lära sig hantera nya situationer: lärande genom “trial-and-error”. Misstag finns på minussidan i en mental "balansräkning" som till övervägande del består av plus, men varje framgång har ett pris. Many people regard errors as something akin to a divine curse. They see fallibility as a design defect picked up along the course of human evolution. In doing this, they are confusing the act with its outcome. There is nothing intrinsically wrong with human error; indeed, as we shall see in a moment, it stems from highly adaptive cognitive processes. For the most part, it is not the error per se that is bad; rather, it is the man-made context in which it occurs that is now so unforgiving. How can errors be adaptive? One very obvious way is trial-and-error learning. The only means by which we can learn how to deal with novel situations is by making mistakes. Errors act like a flare path to mark out the limits of acceptable performance: if we keep within these markers, we eventually find the right way to act. Of course, this only works safely in relatively benign circumstances. And therein lies the problem: rapid advances in technology have taken much of human behaviour into environments that lie beyond its natural evolutionary boundaries.

8 Den mentala balansräkningen
Automatiskt handlande, som är nödvändigt i många situationer, gör oss benägna att handla utan att tänka (förbiseenden). Avgränsad uppmärksamhet, vilket krävs i vissa situationer, kan göra oss till offer för ouppmärksamhet och tunnelseende. Långtidsminnet innehåller "miniteorier" snarare än fakta. Det gör oss benägna att bara se signaler som bekräftar våra teorier och att inte se andra signaler. Each entry on the ‘credit’ side of the mental balance sheet carries a corresponding ‘debit’: The ability to automate our actions so that we don’t have to make a conscious decision about how to carry out each one is a tremendous advantage. Continual ‘present-mindedness’ would be insupportable. We would never get out of bed in the morning. But our mental ability to delegate the control of highly skilled or habitual action sequences to non-conscious mechanisms also makes us liable to absent-minded slips of action—like getting into the bath with your socks on. Mostly these are inconsequential, but occasionally—especially in error-critical situations—they have have damaging outcomes. Having a resource-limited attention span makes it possible for us to carry out coherent sequences of planned action, but it also makes us liable to information overload when too much is happening at the same time for us to process it. This is usually a good thing, but not necessarily during an emergency in the ICU or operating theatre. Long-term memory does not contain raw facts, rather it holds a very large collection of ‘mini-theories’ about various aspects of the world. These ‘knowledge structures’ help us to make sense of the world, but they also leave us open to ‘confirmation bias’ when we stubbornly cling on to an initial hunch despite evidence to the contrary.

9 Otillräckliga beslutsunderlag
Fel uppstår när mentala processer, som krävs för för ett riktigt beslut, är ofullständiga. Ofullständigheten tar sig många olika uttryck - ouppmärksamhet, bristande kunskaper, sparsamt med viktiga data, glömska, osv. När de mentala processerna är ofullständiga, tenderar hjärnan att få oss att agera på ett sätt som är vanligt, välkänt och verkar passa in i sammanhanget. Ett agerande som är lätt att ta till. Errors are not random events. They arise because some aspect of the mental processing necessary to achieve correct performance is—in various ways—under-specified. That is, not enough information is brought to bear at a critical moment to ensure successful action. Under-specification can occur for many reasons: we may be distracted or preoccupied at some critical point in an actions sequence; or we have forgotten some crucial fact; or the information arriving at our senses is sparse and ambiguous; or we possess an incomplete understanding of the current problem. Despite the many ways that under-specification may occur, its consequences are highly predictable. The mind ‘defaults’ to a response that is commonplace in that particular context—what we might call a ‘strong habit intrusion.’ This response may be incorrect, but the mechanism that produces it is a highly adaptive way of dealing with uncertainty, as the next two slides will show.

10 Vem var det som sa. . . Lamporna släcks i hela Europa,
vi kommer inte att få se dem tändas igen under vår livstid. Most people don’t know the correct answer, but they usually make a highly appropriate guess. They look at the quote and think: it was probably some English-speaking statesman speaking on the eve of some cataclysmic event, probably a world war. This narrows the possible search to a very small number indeed. A quotation like this also assumes that the speaker is very well known.

11 Min gissning att de flesta trodde Winston Churchill
men det var faktiskt-- Sir Edward Grey The answer given by most Europeans is ‘Winston Churchill’. He, after all, is probably the most conspicuous of the class ‘English-speaking statesman on the eve of a world war’—in this case, the Second World War (the one that is most familiar). You might almost persuade yourself that you can hear him speaking. Actually, it was Sir Edward Grey who said it. He was the (now largely forgotten) British Foreign Secretary in 1914 (the beginning of the First World War). He was speaking to the Italian ambassador on 4th August 1914 (the day war broke out) as they were both watching the gas lamps being snuffed out on Horse Guards Parade. Now the fact that we can predict people’s errors in these and similar circumstances means that we understand to some degree the processes by which they arose. It’s a highly adaptive kind of psycho-logic: If in doubt, identify the most likely speaker. It may be wrong, but it’s often a very useful way of dealing with ignorance. People say they were guessing, but they weren’t. They were employing two basic ‘rules of thumb’: match like with like and then choose the most salient item that comes to mind—a process called ‘frequency-gambling’. This simple but adaptive mechanism is implicated in a large proportion of our errors.

12 Hemska fel, dåliga människor
Ofta är det de skickligaste människorna som gör de allvarligaste misstagen, eftersom de har en tendens att tänja på gränserna. Cirka 90 % av misstagen är inte avsiktliga. Vissa människor har dock ett medvetet riskbeteende - drogmissbruk, för mycket arbete, för lite återhämtning etc. Var drar ni gränsen hos er? There are a number of deep-rooted psychological tendencies that lead us to blame people for their errors—and the worse the consequences of the error, the more culpable is its perpetrator judged to be. The first of these is the fundamental attribution bias. People have a natural tendency to attribute a person’s actions—particularly if they are thought to be undesirable—to some characteristic of the actor’s personality or temperament, ignoring the circumstantial constraints on his or her actions. The second is the illusion of free will. We place such a high premium on the belief that we are the determiners of our own actions—the ‘captains of our destiny’—that we impute this to other people, even when their actions, as in the case of errors, are not actually intended. The third tendency is the just world hypothesis. This is the assumption shared by most children and many adults that bad things only happen to bad people. In its extreme form, we will even blame the victims of accidents for their own misfortune. The reality is usually different. One of the basic rules of error management is that the best people can sometimes make the worst mistakes. Evidence of this can be found in a multitude of accident reports. The best people are often performing the most difficult tasks, and are thus more liable to error. But, as discussed in the previous module, not-so-good people also make bad errors. Deciding where the line is to be drawn between honest errors and unacceptable unsafe acts is the first step along the road to engineering a safer culture.

13 Misstag är varken slumpmässiga eller särskilt unika
Fel inträffar när . . . man vet vad man ska göra, men det går inte som man har tänkt (glömska, förbiseenden, felgrepp och fumlighet) man tror att man gör rätt, men uppfattar inte varningstecken, tillämpar en dålig regel eller tillämpar inte en bra regel (regelbaserade misstag och/eller överträdelser) Man vet inte riktigt vad man gör (kunskapsbaserade misstag i nya situationer) There is a widespread assumption that errors are unpredictable events which occur ‘out of the blue’ and are highly variable. This is an understandable point of view when we consider what it takes to perform a task correctly. There is usually only one way of doing this, or, at best, very few; but each step in a planned sequence of actions provides an opportunity to stray along a multitude of wrong pathways. Think of boiling an egg. At what points and in how many ways can even this relatively simple operation be bungled? The list of possibilities is very long. Fortunately, the reality is quite different. Human error is neither as unpredictable nor as varied as its vast potential might suggest. For the most part, errors take a relatively small number of systematic forms. Moreover, these error types appear in very similar guises across a wide range of mental and physical activities. Such widespread recurrences owe their existence to the fact that they are shaped by the mental control processes—planning, storing, executing and monitoring—that are involved in all human activities. They are also markedly influenced by the circumstances in which the actions were performed and by the condition of the actor. Virtually all of human error can be assigned to one or other of the now familiar categories shown on the slide.

14 Några exempel Läkaren skriver ut ett recept på 5 mg istället för 0,5 mg (en miss). Sjuksköterskan delar ut medicinen för sent (ett förbiseende). Läkaren använder fel formel för att beräkna antibiotikadosen till en patient med njursvikt (regelbaserat misstag). Läkaren korrigera inte felet eftersom han/hon inte känner till patientens njursvikt (kunskapsbaserat misstag). Here are some HC examples of each of the various error types. It would be extremely useful if you now thought of different examples of each type drawn from your own experience. Try writing them under the headings below. SLIPS LAPSES RULE-BASED MISTAKES KNOWLEDGE-BASED MISTAKES

15 Två perspektiv på misstag och erfaren personal
Misstag sker sällan, men kan orsaka vårdskador. Antagande: erfaren personal som följer goda rutiner, gör inte fel. I verkligheten är misstag vanliga , men råkar ibland bli sista länken och den utlösande faktorn i en händelsekedja, som funnits latent under lång tid i systemet. Although it is recognised that highly trained professionals like airline pilots and doctors are human and therefore fallible, the passengers and patients, together with the professionals themselves like to believe that that such errors are very rare. In the case of medicine, doctors and patients unconsciously collude with one another in sustaining this therapeutic belief. But evidence from hi-tech surgery should be sufficient to challenge the comforting myth that highly trained professionals make very few errors. The reality is that errors among highly trained professionals are commonplace. But they are mostly inconsequential. The best pilots and surgeons are not so much error-free as error-aware. They anticipate the likelihood of errors and practice the mental skills necessary to achieve effective error-recovery strategies. The isolated errors of highly trained professionals are rarely sufficient by themselves to bring about an adverse event. It is certainly the case, however, that errors made by frontline workers are occasionally necessary to complete an accident sequence that might have been a long time in the making. Most adverse events in complex systems arise from the concatenation of active failures and latent conditions—where the latter may be present at many levels of the organisation.

16 Avvikelser vid kirurgi
En studie baserad på observationer av 21 kirurger under 165 kärloperationer på 16 kliniker i Storbritannien. I genomsnitt skedde 7 avvikelser per operation varav 1 allvarlig (livshotande) 6 tillbud (störningar i arbetsflödet, irritation) Över 50 % av de allvarliga avvikelserna hanterades framgångsrikt, men bara 20 % av tillbuden. A recent British study made direct observations of 165 arterial switch operations (usually carried out on very young babies) performed by 21 surgical teams in 16 centres in the United Kingdom. These are very high-technology procedures that may last five or six hours. They also take the surgeons close to the limits of human performance capabilities in the high demands made upon their psychomotor, cognitive, management, and communication skills. Of particular interest to the researchers were the adverse events that posed either greater or lesser threats to the patient. These events arose almost invariably from errors made by the surgical team and were of two kinds: major events that were life threatening, and minor events that were not in themselves directly hazardous to the child, but which acted as irritants and disrupted the surgical flow. On average there were seven events per procedure, one of them major, and the remaining six were minor Over half of the major events were successfully compensated and had no impact on the baseline fatality risk (about four or five deaths in 100). But only 20 per cent of the minor events were caught and recovered. The good compensators achieved the best outcomes, but their ability to recover errors was inversely related to the total number of minor events they experienced during the procedure.

17 Hantera det som går att hantera
Det är mänskligt att fela. Vi kan inte ändra på människans natur. Men vi kan ändra på människors arbets-förhållandena. This slide summarises the main message so far: Changing situations is more effective than trying to change human nature.

18 I alla typer av riskfyllda aktiviteter
Upprepas ett mönster Inträffar samma sorts fel i samma sorts situationer. Eftersom olika individer är inblandade i dessa situationer, måste orsakerna vara de bakomliggande riskerna och svagheterna i systemet och inte olycksbenägna männsikor. This slide reiterates what was said earlier about recurrent error patterns, or error traps. The issue here is not error-prone people but error-prone tasks and circumstances. How many times, for example, has vincristine (a drug used in the treatment of leukaemia) been injected intrathecally (spinally) rather than intravenously? There have been more than 30 cases across the world. In all instances the patient died a painful and protracted death. How many other recurrent adverse events can you think of? What about cutting the main bile duct during laparoscopic cholecystectomy? What others?

19 Vissa risker är uppenbara
This lack of differentiation in the labelling and packaging of three quite different fluids is more the norm than the exception in HC.

20 Andra är som lömska sprickor som sammanstrålar i systemets skyddsbarriärer
But other error traps have a long history and are more subtle. The brick wall in the picture represents the system’s defences against some known hazard (the intrathecal injection of vincristine, for example). These barriers and safeguards take many forms: protocols, hospital procedures for wards and pharmacies, double-checking, sign-offs, physical distinction (i.e., intravenous and intrathecal drugs should not be in the same package and should not be administered on the same day, and so on. We have included a detailed case study (see Case Study Material) of how all of these defences were insidiously breached by good intentions and workarounds, so that the last barriers—the junior doctors on the spot—were suckered into making a fatal error.

21 Läkemedelsfel: många orsaker
% händelser 10 20 30 40 50 60 Verksamhet/utbildning Kommunikation Förvaring/tillgång Informationsstöd Kompetens Märkning/handledning Störning These data, taken from the UK Department of Health’s publication, ‘An Organisation with a Memory’ (2000) make it very clear that medication errors rarely occur as the result of a single factor. Rather they involve the subtle interaction of several different causes and conditions.

22 Undanröj fallgroparna
Den främsta syftet med ett avvikelse-rapporteringssystem är att identifiera befintliga svagheter och risker. Att hitta och eliminera dessa svagheter och risker är en av huvuduppgifterna i patientsäkerhetsarbetet. This module has led to this crucial point. When you understand the nature of error and the circumstances that provoke it, you can start to look through your incident data for recurrences—or error traps. Removing these error traps from within your organisation is one of the main functions of error management. It need not be expensive. But it does take commitment and resolution to carry it to a successful conclusion.

23 Grunderna i patiensäkerhetsarbetet
Att förebygga fel och misstag Identifiera och eliminera risker Använda utrustning med användarvänligt gränssnitt Utbilda, instruera och avrapportera Begränsa effekterna av avvikelserna Utgå från att det alltid kommer att begås fel Utbilda personalen till att upptäcka och åtgärda fel Skapa robusta system As mentioned earlier, the only thing that distinguishes medical errors from other types of human fallibility is the healthcare context. This means that we can look to other domains for information about error management. There is nothing new in the idea of error management (EM). Several tools are already being used in HC facilities (e.g. counting swabs and instruments before and after a surgical procedure). But the implementation of a principled EM programme is very rare indeed. Most existing attempts at EM are piecemeal rather than planned, reactive rather than proactive, event-driven rather than principle-driven. They also largely ignore the substantial developments that have occurred in the behavioural sciences over the last 20 to 30 years in understanding the nature, varieties and causes of human error. Other problems with existing EM methods include: ‘Fire-fighting’ the last error rather than preventing the next Focusing on errors rather than error-provoking conditions Focusing on personal rather than situational factors Heavy reliance on exhortations and sanctions Failure to distinguish recurrent error traps Failure to use safety-related information effectively

24 Det svåraste med säkerhetsarbetet är . . .
att få det att fungera – att leda säkerhetsarbetet. Säkerhetsarbetet kommer nästan alltid att misslyckas om det uppfattas som en extrauppgift. Säkerhetsarbetet måste integreras i de policys, rutiner och aktiviteter som styr den normala, dagliga verksamheten. Säkerhetsarbetet är lika viktig som vårdarbetet. Error reduction and error containment are not easy, but their difficulties are insignificant in comparison to the problems associated with the management of EM. There is an important distinction to be made here between process and product. Religion, for example, is almost all process (praying) with little or no product (miracles). A piece of modern electronic equipment, on the other hand, is almost all product and hardly any process. You buy it. You plug it it in, switch it on, and it does what it’s supposed to do thereafter. EM requires a lot of process. You can’t just buy a package, implement it and then tick it off the list of things to do. It needs continual attention, tweaking, massaging, tuning and adjustment—it’s an art form rather than a technical product. In that respect, it is not much different from any other type of management process. As indicated above, it is crucial that the EM process is seamlessly integrated into normal managerial activities. If it is perceived as extra, an ‘add-on’, it will not survive.

25 Det finns inte ett bästa sätt
Det finns ingen magisk lösning. Effektivt säkerhetsarbete kräver olika insatser på olika nivå inom organisationen. Det finns inte heller någon självklar bästa kombination av metoder och arbetssätt. Olika lösningar passar för olika organisationer. Man måste anpassa sina angreppssätt till den rådande kulturen. There is no one best way. You need to come up with a mix of practices and measures that suit your particular culture. Similarly, there is no one single universal package that will address all your error problems. You need a variety of tools aimed at different parts of the system: the person, the team, the task, the workplace, the organisation and the system at large.

26 Flera principer för säkerhetsarbetet…
De skickligaste personerna begår ibland de värsta misstagen. Med välutbildade och välmotiverade medarbetare är det lättare att rätta till arbetsförhållandena än att ändra på människorna. Samma risker orsakar samma slags misstag, oavsett vem som är inblandad. Identifiera riskerna och eliminera dem. Cease treating errors as a moral issue. Fallibility is the norm, not the exception. There are many pressures upon doctors to bury their errors and to hide them both from their students and the lay public. This creates the impression that only bad doctors make bad errors. But one of the basic rules of human error is that the best people can make the worst mistakes. And, it is the nature of medical practice, that these errors can damage vulnerable people. This is a circumstantial issue, not a moral one. HC professionals are well-trained and highly motivated to avoid harming patients. Appreciate that while it may be emotionally satisfying to name, blame and shame those that make errors, this all-too-familiar reaction has little or no remedial value. Worst of all, it isolates the individual from his or her systemic context—thus preventing us from identifying the remediable error-provoking features of the workplace. We can only learn about situational error traps if people report their errors and near misses. But, as the Harvard Medical Practice Study showed, self-reports in a blaming, sanctioning and litigating culture underestimate the true incidence by a factor of at least fifty.

27 Säkerhetsarbetet - vad är siktet inställt på?
Individen Uppgiften How do you best reduce errors and limit their bad effects. This slide shows four possible target areas: the person, the task, the situation and the organisation as a whole. As we shall see next, most organisations aim for the person because they believe that people are more changeable than situations. Arbetsplatsen Organisationen

28 De flesta organisationer siktar på individerna
Kritiserar, hänger ut och omskolar Fastställer en ny rutin Letar efter "hjärnspöken" Typical responses to errors in many different industries are as follows:- Blame and retrain: ‘Carpet’ the error-maker, or discipline him, or tell him to be more careful, and then, if necessary, send him for retraining. Write another procedure: All industries tend to write procedures to prohibit actions that have been implicated in some event or incident. The result is that the range of permitted actions is often less than the range of actions necessary to get the job done. Search for the ‘missing piece’: When these measures fail (and they usually do), managers start looking for psychological ways of finding the piece that will remove violations and errors. Somewhere out there, they think, is a shrink or a psychologist who can come up with the ‘magic bullet’ solution.

29 Men det är bättre att sikta på . .
Uppgiften + Arbetsplatsen + Organisationen Effective EM focuses most of its efforts on:- Identifying and correcting error-prone tasks Improving error-producing work situations Identifying and correcting latent organisational ‘pathogens’.

30 Mental beredskap Utgå från att fel kan och kommer att inträffa.
Stanna upp och tänk efter. Identifiera de omständigheter som bäddar för misstag. Ha beredskap för att hantera oförutsedda händelser, avbrott och störningar. Träna mentalt på komplexa procedurer. There is considerable evidence to show that mental preparedness—over and above the necessary technical skills—plays a major part in the achievement of excellence in both athletics and surgery (Orlick, 1994) The “three-bucket” model and its associated toolkit emphasise the following aspects of preparedness. Accept that errors can and will occur. Assess the local “bad stuff” before embarking upon a task. Have contingencies ready to deal with anticipated problems. Be prepared to seek more qualified assistance. Do not let professional courtesy get in the way of checking your colleagues’ knowledge and experience, particularly when they are strangers. Appreciate that the path to adverse incidents is paved with false assumptions.