Sunday, 9 December 2012

Blame it on human error

Blame it on 'Human Error', after all everybody knows that to Err is Human

Can you see what is happening in the pictures above? Of course you can. They are two infusion pumps with two different types of numerical key pads.

Can you now see how easy it would be for a tired nurse or an even more tired doctor when they are really busy at 3 am to confuse between the keypads and make a mistake?

Would that be counted as human error? Probably yes. But is that human error? Certainly not. This situation would be without doubt a systems error at two levels. Firstly for the manufacturers not standardising numerical keypads. Secondly for the buyer/healthcare facility for buying and using pumps with two different key pads in their premises. By doing so we have designed our system to fail, we have designed for the humans in our systems to fail. Avoiding that is what human factors is all about.

Let us assume that a clinician made an error in a facility that both these styles of numerical keypads in use in say adjacent beds/wards/floors. The investigation would only show that the clinician made a human error in pressing the wrong numbers in that particular key pad. That would be a fact. Would that be the whole truth? No. A standard investigation would not show that the error was triggered by the system by having those two types of keypads in adjacent areas. The investigation would probably end by stating that individual clinicians are responsible for their actions. Then the clinician would be sanctioned against, sometimes that is insultingly yet euphemistically called providing enhanced support and training for the concerned clinician.

The reason called 'human error' becomes a convenient parking lot for system errors that mostly go unrecognised due to poor management and poor investigators who have not much clue about human factors. Human error is easy, its tangible, you have someone clearly responsible and someone who has failed in their responsibility. Every one understands human error. System error recognition is very complex, its often fuzzy, once recognised there is no one to 'blame', to be held responsible. After all that, resolving system errors takes patience, time, energy and technical skills which many would pretend to have. It is frightening to imagine how many clinicians might have been afflicted with the 'human error' label when the actual reason was the system.

Now, if you were remotely responsible for patient safety, you will now rush out into your healthcare facility to make sure that you have only type of numerical keypads at your facility for these. That is at the narrow level. At the intermediate level please ask yourself how many other items that are non-standard at your place of work that confuses people and compels them into making an error. Go looking for them and eliminate them.

At a bigger picture level we are beginning to believe that 'Human Error' is often a cop out clause for managers who don't fully understand systems or processes. To err is indeed human but to design for failure and then blame it on 'human error' is inhuman.

Follow me on twitter @HemadriTweets

PS: Note the manufacturer of the pumps in the picture above is only an illustration to make a wider point, those pumps are good and overall have served patients well.  So please do not get hung up and pious about a particular product or company. I have also found that my windows calculator and my samsung phone calculator have different numerical keypads which are different from my computer keyboard's numerical keypad. How confusing is that? Is it any wonder then if some poor bloke at the office goofs up? 


bevb said...

The post offers a good illustration of how design can influence safe behaviors. Unfortunately, consumer driven industries drive their devices by uniqueness rather than safety. Uniqueness means the device is easily seen as different than another manufacturers. As Hemdari points out, in a complex cognitive area like health care this type of branding is no help to the end user...the patient. Again, kudos to Hemdari for pointing out the hospital staff who by now should understand the issues around human factors and why they should suspend their purchase of items that can confuse staff. BTW, Human Factors is Ergonomics and vice versa. Ergonomics is not just table and chair, but a thorough evaluation of the tools and environments where workers make their livelihoods.

Ross Taylor said...

Human errors we easily find out because it's physically and we also know our responsibility so everyone easily understood the human errors but system errors we don't easily find out because it's very complicated, often fluffy, once acknowledged there is no one to find out fault, to be credited. Market Research Report

M HEMADRI said...

Thanks Bev & Ross

Your comments are spot on.

The importance of poor ergonomics in inducing system errors often goes unrecognised.

In my next post out soon we argue that there is probably nothing called human error at all.