Repeating Human Performance Themes in Five Health Care Adverse Events
- 1 September 2002
- journal article
- research article
- Published by SAGE Publications in Proceedings of the Human Factors and Ergonomics Society Annual Meeting
- Vol. 46 (16) , 1418-1422
- https://doi.org/10.1177/154193120204601603
Abstract
Public dread following well-publicized accidents energized the desire to learn from adverse events in health care. This paper summarizes an attempt to partner medical and human factors expertise to identify repeating human performance themes across adverse events. An interdisciplinary team interviewed 30 health care personnel from multiple facilities about five complex medical incidents. Ninety human performance themes were examined for each incident. Of these, ten human performance themes were identified to be salient in at least three of the incidents. Although none of these themes directly point to solutions, they increase our understanding of recurring themes across medical cases and can point to similar themes, and how they have been addressed, in other high-consequence, complex, socio-technical domains, such as aviation.Keywords
This publication has 13 references indexed in Scilit:
- Shift Changes, Updates, and the On-Call Architecture in Space Shuttle Mission ControlComputer Supported Cooperative Work (CSCW), 2001
- The Need for Organisational AnalysisCognition, Technology & Work, 2000
- Cognitive Work AnalysisPublished by Taylor & Francis ,1999
- Identification and classification of the causes of events in transfusion medicineTransfusion, 1998
- Promoting Patient Safety by Preventing Medical ErrorJAMA, 1998
- Team Play with a Powerful and Independent Agent: Operational Experiences and Automation Surprises on the Airbus A-320Human Factors: The Journal of the Human Factors and Ergonomics Society, 1997
- Cockpit Checklists: Concepts, Design, and UseHuman Factors: The Journal of the Human Factors and Ergonomics Society, 1993
- Critical decision method for eliciting knowledgeIEEE Transactions on Systems, Man, and Cybernetics, 1989
- Cognitive aspects of information processing: III. Set for speed versus accuracy.Journal of Experimental Psychology, 1966
- The critical incident technique.Psychological Bulletin, 1954