Human+Error

== = = toc ="To Err is Human"=

An error is: “the integrated accidental causation of an accident, injury or death, whether or not there are multiple contributions, many systems, different error types or multiple persons involved” (Human Error).

=What is Human Error?=

“Human error is an imbalance between what the situation requires, what the person intends, and what he/she does. (Human Error)” By simple definition “**Human Error**” can be described as a mistake made by a human.

=When does Human error happen?= //Humans have limited abilities thus mistakes are likely to happen://
 * When one plans to do the right thing but results in the wrong outcome.
 * You apply the wrong solution to a situation
 * Avoidance, neglect to be aware of warning signs
 * Failure to read instructions
 * Inability to formulate an appropriate mental model

= = =Approaches to Errors:=
 * Person Approach
 * System Approach

**Person Approach:**
The person approach is described as the ‘individual error’. This is when the individual is blamed for things such as their inattentions, forgetfulness or their other moral weakness.The person approach is the most commonly form of error which is recognized and applied. It is easier to blame individuals versus the actual system or device. However, simply focusing on the individual error this leads to isolation of potential unsafe acts from systems context. (Reason)

**The System Approach:**
The systems approach “concentrates on the conditions under which individuals work and tries to build defenses to avert errors or mitigate their effects” (Reason)

=The Swiss Cheese Model:= A human error approach proposed by James Reason (1990) is y referred to as the “Swiss cheese” model of human error. The model describes the four levels of human failure, each influencing the next. “Every step in a process has the potential for failure. The holes are considered opportunities for a process to fail, and each of the slices as “defensive layers” in the process. An error may allow a problem to pass through a hole in one layer, but in the next layer the holes are in different places, and the problem should be caught. Each layer is a **defense** against potential error impacting the outcome. (Paitent Safety) "For a catastrophic error to occur, the holes need to align for each step in the process allowing all defenses to be defeated and resulting in an error. If the layers are set up with all the holes lined up, this is an inherently flawed system that will allow a problem at the beginning to progress all the way through to adversely affect the outcome. Each slice of cheese is an opportunity to stop an error. The more defenses you put up, the better. Also the fewer the holes and the smaller the holes, the more likely you are to catch/stop errors that may occur". (Paitent Safety)

=Consequences of Human Error:= Depending on the severity of the situation, results may vary.

= = =Documenting the Errors:= Effective risk management crucially relies on establishing a method of reporting. A detailed analysis of errors mishaps, incidents, near misses, and "free lessons," we have no way of uncovering recurrent error traps or of knowing where the "edge" is until we fall over it. (Reason)

=Norman on Errors:=

"Norman argues that the behavior "human error" is far easier to predict than some other kinds of errors like mechanical and electrical. There are certain models and patterns in the way people make errors and if they are accounted for in the initial design the number of "human errors" will be dramatically decreased. Probably we should even change our whole attitude towards errors. We should say that they occur because the design is bad and not because the users are not careful and made an error".
 * Design for error**

Here is a brief summary of the 4 most important design for error principles that Norman suggests: 1.Understand the causes of error and design to minimize those causes. 2. Make it possible to reverse actions - to "undo" them - or to make it harder to do what cannot be reversed. 3. Make it easier to discover the errors that do occur, and make them easier to correct. 4. Change the attitude toward errors. Think of an object's user as attempting to do a task, getting there by imperfect approximations. Don't think of the user as making errors; think of the actions as approximations of what is desired. ( Stoytchev, Alexander)

=Works Cited=

Benyon, Turner & Turner; 2005. //Designing Interactive Systems: People, Activities, Contexts, Technologies.//

Reason, James. "Human Error: Models and Management." __Bmj.Com__. 18 Mar. 2000. University of Manchester. 4 Dec. 2006 <[|http://www.bmj.com/cgi/content/full/320/7237/768>.]

"Sharing Knowledge." __Human Error__. Oct. 2004. Healthcare of BC. 4 Dec. 2006 <[|http://control.ohsah.bc.ca/media/Human_Error.pdf>.]

Stoytchev, Alexander. "Donald Norman's Philosophy on Design for Everyday Interaction." 7 Dec. 2006 <[|http://www-static.cc.gatech.edu/classes/cs6751_97_fall/projects/follow_me/exam/alexandre.html>.]

"Swiss Cheese Model." __Patient Safety- Quality Improvment__. 2005. Duke University Medical Center. 4 Dec. 2006 <[|http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html>.]

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