Reduce Human Error


Rooney, James J.; Vanden Heuvel, Lee N.; Lorenzo, Donald K.   (2002, ASQ)   ABS Consulting, Knoxville, TN

Quality Progress    Vol. 35    No. 9
QICID: 18308    September 2002    pp. 26-36

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Article Abstract

Human error is most often determined to be the cause of events leading to death or serious injury at healthcare facilities. When the responsible person is coached, disciplined, or perhaps even fired, managers and team leaders feel fairly confident that the mistake will not happen again, but experience shows that mistakes will likely recur. The challenge for healthcare management is to implement systems that, rather than placing the blame on ill trained or poorly motivated workers, analyze near misses and sentinel events so root causes can be determined and corrective actions implemented. Human errors are a natural and inevitable result of the variability of human interaction with a system. To minimize errors, managers must ensure the healthcare worker/machine interface is compatible with the capabilities, limitations, and needs of the worker. When seeking ways to improve human performance, managers must address two basic types of errors: those caused by human characteristics unrelated to work, and those related to the design of the work situation. More than 80 percent of errors result from the design of the work situation, which managers can directly control. Many errors can be prevented by ensuring that clear, accurate procedures and job aids are available and used by all workers. Training ensures healthcare workers possess the basic skills necessary to effectively perform their functions. Allocating time and resources to understanding human factors will significantly help improve overall system performance and process safety. Sidebar articles describe ASQ's role in reducing healthcare errors, how ASQ is facilitating application of ISO 9000 to Healthcare, and the Leapfrog Group's coalition to improve patient safety.


Employee relations, Standards and specifications, Prevention, Root cause analysis (RCA), Human relations, Human resources (HR), ISO 9000:2000, Health care, Standard errors

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