In an increasingly litigious world, intolerant of failure, error has become inextricable linked with fault and blame. Here, error is considered in hindsight by agents in positions of power or with specific agendas. Something happened and someone must pay. Clichés such as ‘error is natural’ or ‘no one intends to make a mistake’ carry little weight. Unfortunately, this interpretation of ‘error’ feeds into debates in the safety domain but simply rejecting the term misses the point.

To understand the importance of error we need to reflect on the nature of the world. Imagine a small pile of sand on a table. As you add more grains of sand, the cone will build, maintaining its shape until, eventually, the next single grain will trigger a cascade. Sand will slip down the side of the cone until a new shape is stabilised. And, so, the process goes on. The cone is stable under most circumstances but just a single grain of sand can trigger a transition to a new stable state. The world, then, exists in a state of self-organised criticality. This is important. If the world was too stable, it would not be able to respond to change. Instability, then, is an adaptive property. It also means that work must contend with this inherent instability. 

We need to be constantly adapting to events as we encounter them, which might not be how we anticipated them at the outset. It is this mismatch between ‘expected’ and ‘actual’ that is one source of error.

But there is a more fundamental process that gives rise to error. All action flows from decisions made by a brain encased in bone. It has no direct access to the outside world. The brain acts like a Bayesian probability engine. The brain creates a set of expectations about the nature of the world, and these are compared with sensory inputs. Any discrepancies – errors – are resolved until our perceived reality meets a threshold. Our investment in establishing ‘reality’ is just enough to support whatever action is needed to achieve our goals. This last statement presupposes that all action is goal directed. Error, in this context, is feedback from the world about the correlation between our actions and our progress towards our goal. In fact, error is information that reduces uncertainty. In this sense, error allows us to fine-tune our actions.

Studies of airline pilot performance reveal that about a third of errors committed by crew go unnoticed. They are seen by the trained observer, but not by the perpetrators, and barely 1% of these errors have any sort of impact on the operation of the aircraft. This suggests two things: first, in aviation at least, the operation is resilient and can cope with error; second, the consequence of error does not seem to impinge upon the crew’s understanding of what is happening to the extent that they need to take any action. However, when an error does come to the attention of the crew, a response is needed. Again, studies show that a significant proportion of detected errors are simply ignored by crew. Fewer than half require a positive intervention. It is fashionable to talk about error ‘management’. In fact, crew do not ‘manage’ errors: instead, they respond to the new set of circumstances created by the error. 

Error is the trace you leave behind, like the wake of a ship. You play what is in front of you and don’t look back.

But what about the ‘things that go right’? Here is a game you can play. Imagine you are watching someone in the workplace. How do you know things are going right? Probably, it’s because you haven’t seen anything going wrong. We are designed to detect ‘wrong’ because that is what will save our lives. It’s an evolutionary thing. We are blind to ‘right’ because that is simply our expectations – the brain’s prediction – being met. That said, have you ever been impressed by something you have seen at work? Again, this is our prediction not being met, but in a surprising way rather than a negative way.

Surprises, like failures, are learning opportunities. Both allow us to refine our internal representations of tasks, leading to better goal specification and richer action sequences directed at attaining that goal. 

Error, then, is not only good but also essential. The original meaning of ‘error’ was to wander. It is not the wandering that really matters but the path people were trying to follow in the first place.

Key take away points:

1. After a process failure, the goal is to explain the gap between planned and actual. Culpability comes a distant second.

2. Most responses to adverse events merely shift the point of failure.  The work will be no less variable and the role of error will not change.

3.  If you really need a 'Just Culture' policy it suggests that the people with power do not understand error.

Fran talks to Dr Neil Spenceley, Clinical Director, Royal Hospital for Children, Glasgow and Dr Carl Horsley an Intensivist working at Middlemore Hospital in Aukland, New Zealand. Neil and Carl talk about incorporating Human Factors into their every day clinical work, how they do it and why they are so passionate about the science.

From librarian and healthcare assistant to Human Factors specialist

Fran speaks to Jane Higgs and Siobhan Burns about their transition into Human Factors as a second career. Jane is currently a PhD student at Loughborough University and moved into Human Factors following a career as a librarian. Siobhan Burns is an Ergonomics and Human Factors Adviser at University Hospitals Birmingham and started her career as a Healthcare Assistant before moving to Manual Handling Training and then Human Factors. Hear their experiences, what their university courses did and didn't prepare them for and listen to the utter passion they have for the science.

Exploring SEIPS with Professor Pascale Carayon

Fran speaks with Pascale Carayon, a Professor in Industrial and Systems Engineering at the University of Wisconsin Madison. Pascale talks about her vision for the SEIPS (System Engineering Initiative for Patient Safety) framework, which she has been working on for many years. During the conversation, Pascale gives some valuable advice to those who are new to using SEIPS such as focussing on the interactions between the elements of the model, such as the organisation, the task, and the tools. Future possible developments for the framework were considered such as making a connection between patient safety and well-being such as stress and burnout.  

Human Factors across the Atlantic

Fran welcomes Ken Catchpole to discuss the differences between the American and British healthcare systems and their effects on healthcare Human Factors. Fran and Ken discussed the differences between the US and the UK in terms of healthcare human factors integration, with both countries having a similar level of integration. They concluded their discussion with the importance of supporting Human Factors specialists in solo roles. 

Discovering the field of Human Factors: A conversation with Steve Tipper

Fran speaks to Steve Tipper, a Chartered Human Factors Specialist working in the Patient Safety Team at University Hospitals Coventry and Warwickshire NHS Trust. The two explore what Human Factors integration into a healthcare organisation looks like.

Exploring healthcare Human Factors: Leveraging experiences from transportation to improve care

Fran talks to Steve Shorrock, a Chartered Psychologist and Chartered Ergonomics and Human Factors Specialist who has experience in the transportation industry. Steve discusses why it is important to integrate Human Factors into healthcare and what can be learned from his transportation experience. He believes that Human Factors should be integrated into all aspects of healthcare, from design to implementation and that Human Factors is essential for safety, efficiency, and effectiveness in healthcare.

It’s not your fault

Society’s development has accelerated at warp speed over recent decades and shows no signs of slowing down. Unfortunately, our brains have had trouble keeping up and are trying to function in a highly complex, rapidly changing environment while still running on caveman software!

This dichotomy is the essence of what I explore in my book, Oops! Why Things Go Wrong. The mismatch between the fast-paced environment and our inability to respond appropriately results in errors inevitably occurring. This is merely an inconvenience in many areas, but in safety critical industries such as aviation and healthcare it can literally mean life or death.

Society is also, unfortunately, very intolerant of error, especially in others. We need to change this mindset.

Error is nothing to be ashamed of. The only way to even come close to avoiding error is to be so cautious and risk averse that we stifle innovation and, in healthcare, avoid intervention in any but the easiest of cases.

Your good health

I was sitting at the nurses’ station on a ward in a major Belfast hospital. The bed closest to me had the curtains pulled. The ‘crash’ team had just left and behind the curtains was an elderly lady who had just died from irrecoverable cardiac failure, precipitated by me prescribing her more intravenous fluids than her ailing heart was apparently able to handle. I had just killed my first patient.

My training as a doctor focused primarily on not making mistakes. They were considered unacceptable and something not to be discussed, especially if you hoped to progress up the career ladder. However, sticking our heads in the sand is not the answer. In developed countries, for example, it is estimated that around 10% of hospital admissions suffer an adverse event with around 5% of these causing or contributing to their death. Error is estimated to cost about 10% of a country’s healthcare budget despite up to 70% being considered preventable. In the UK alone, that’s over £15 billion.

When I moved out of healthcare and retrained as an airline pilot, I was somewhat disorientated by a completely different approach to error. It was seen as inevitable and, therefore, something to be dealt with, not to be ashamed of.

It took me quite a while to come to terms with this different mentality, but over time I realised what a valuable approach it was.

Again, the statistics are clear: total deaths globally in commercial jet aviation in 1977 numbered around 3.000 people while currently figures are less than 1,000 annually despite an almost 10-fold increase in passenger numbers. Indeed. in 2017 the number of deaths globally was zero! This is due largely to our focus on Human Factors since the late 70s.

Twelve years ago I started to convey the lessons from aviation to a healthcare audience with limited success. However, recently the mindset seems to have changed. Staff appear more accepting of the inevitability of errors regardless of how hard they work. Patients, too, no longer expect their doctors to be perfect, but when mistakes do occur most want truthfulness, an apology and signs that steps are being taken to avoid a recurrence. Healthcare administrators also need to play their part as currently a defensive stance means patients have no alternative but to lodge a complaint or even instigate legal action in order to get answers, which generally leads to a sub-optimal outcome for all involved.

What about everyone else?

Other industries are by no means immune from error. For instance, agriculture has the highest mortality rate amongst workers in the UK and Ireland. UK figures show deaths consistently running at twenty times higher than other industry averages. Errors in the financial industry led to a global meltdown of financial markets in 2008, the effects of which are still being felt.

Error has even become a commodity in recent times. Fake news sites have proliferated to the point where fact and fiction have become increasingly difficult to differentiate. This has been exploited by groups manipulating the information to influence everything from how citizens vote to what shampoo they use. Perhaps it’s time to teach people how to analyse information to try to separate the wheat from the chaff.

In short, we can add error to death and taxes on our list of inevitabilities in life.

So what can we do about it?

The good news is that the problem of error is, at least in part, solvable. Using the toolbox of tried and proven error management strategies, we can make major inroads to reduce its occurrence as well as its impact, greatly improving outcomes for us personally and society generally. The pace of change may have out-run our brain’s ability to manage successfully, but we can fight back. Given that technological developments show no sign of slowing down, it’s time we got started!

• NHS Board Adverse Event Learning Summaries
• Ombudsman Reports on Complaints
• Data from incident reporting and learning systems
• National and organisational management of adverse events policies
• Organisational incident investigation reports
• National and international patient safety curricula

The study identified the following issues in the information reviewed:

• Omitting the ‘systems approach’
• Using the language of blame and human failure
• Overlooking the ‘local rationality’ principle
• Engaging in counterfactual reasoning
• Misunderstanding key concepts

Related reading: 

• HSIB: Learning Response Review and Improvement tool

• The ‘new reality’ in healthcare has most elements of the ‘old reality’, in terms of leadership thinking and organisational culture.
• Those in positions of senior leadership need to be as adaptable and agile in decision making and learning as other professionals.
• Teams can resolve most problems and realise most opportunities, given the time, freedom and resources.
• Team-based quality reviews link reporting directly to regular team discussions, and feed the team’s learning back into training and the governance process.
• Focusing only on learning from adverse outcomes or snapshots of work can result in a lot of lost learning.
• Reducing unnecessary bureaucracy can enable horizontal communication and adaptability in an organisation, making it more effective.
• Issues of wellbeing and diversity are now issues of active reflection and discussion.

• Sleep and learning
• The effects of fatigue 
• Nightshift nutrition
• Standards for rest facilities
• Fatigue: the facts
• Useful tips to aid sleep
• I'm safe - a checklist adapted for clinicians to assess fatigue and fitness to work
• Fatigue tool
• Working well at night
• Rest facilities
• A rested healthcare professional is safer