Medicine has traditionally been one of the most cognitively demanding occupations. This paper from Bob Baron, President and Chief Consultant of The Aviation Consulting Group, discusses the limitations of human performance in the hospital environment. Human factors models are presented and used as an anchor for a randomly selected case study involving a potentially lethal medication error.
The case study’s root cause analysis showed five distinct factors that were causal to the error. The human factors models, in conjunction with an overview of basic human cognition, provide the reader with the tools to understand all five findings of the case study.
This paper will provide a foundation for improving medical safety by creating an awareness of the factors that influence errors in medical procedures.