From the FDA Site…
We also want to call your attention to an interesting article by Drs. Charles Billings and David Woods, in the January 2001 issue of Postgraduate Medicine, called “Human Error in Perspective.” The article starts out with a little history of the so-called “patient safety movement,” including the influence of the famous report of the Institute of Medicine in 1999, with its disturbingly large estimate of patient deaths due to medical error.
The article goes on to stress that it’s not enough to attribute the cause of an adverse event to “human error.” Here’s what they say: ”Attributing adverse events to human error is too often the final step in the investigation, when in fact it should be simply the first step in understanding how and why such failures occur.” They close the article with five prescriptions for success in achieving patient safety:
- First, recognize that failures can and will happen in any system. No one is immune. Look for and find the vulnerabilities in your system through purposeful, interdisciplinary effort.
- Second, understand the problem before you fix it. Applying apparent solutions before you understand the many facets of a problem ensures failure.
- Third, fix the whole system, not just the immediate problem. Chalking an incident up simply to “human error” will give you an incorrect, incomplete or shallow explanation.
- Fourth, simplify, don’t complicate. Make it easier for people to do it right, and harder for them to do it wrong. Simplifying the operation of a system can dramatically improve its reliability by making it easier for the humans in the system to operate effectively.
- And fifth, instead of blaming people, help them to do it better. The authors close the article by saying that the most effective prescription for healthcare system improvement is to support people as they perform their day to day tasks.
Billings, CE and Woods, DD. Human Error in Perspective: The Patient Safety Movement. Postgraduate Medicine – Vol. 109, No. 1: 13-17. January 2001.