Analysis of Human Errors in the Workplace - Literature review Example

Name Course Institution Instructor Submission Date According to Hollnagel, 1993 an error is defined as an action which fails to produce the expected result and/or which produces an unwanted consequence. Human error is the “failure of planned actions to achieve the desired events without the intervention of unforeseeable events” (Reason, 1990). Errors assume a similar pattern in various forms of mental activities allowing analysis of errors on a global scale (Reason, 1990). Human error has been recognized as a primary cause in a significant proportion of organization accidents, (Johnson, 1998 & Guidelines for Preventing Human Error in Process Safety (CCPS, 1994). This has been estimated in up to 90% of all workplace accidents (Feyer & Williamson, 1998). Several Human error classification, models or taxonomies attempt to unravel the causes and other factors responsible human error. Accidents result from a set of interrelated factors each factor being a necessary but not sufficient precondition (Catino, 2000). These factors exist at individual level, organizational level and inter-organizational levels. The human error that causes an accident lies within a series of other underlying factors at any of these levels which may render the accident inevitable under certain circumstances (Reason, 2000). This shows the importance of identifying the mechanisms underlying the cause and dynamics of accidents and to analyze them in depth for significant error management. From subtle non hazardous errors that occur daily to the disasters that have caused massive losses to life and property such as air transport accidents, industrial accidents, nuclear accidents (e.g. Chernobyl disaster, 1986) among others, have underlying human factors. In such cases, the role of human factors is important and should be understood from the organizational context and also in the broad context of organizational field (Reason, 2000). In general human errors types can be Active Error or Latent error. Active error occurs during execution of plans by front line operators such as control room crews, pilots and air traffic controllers (Reason, 1990) while Latent errors are the less apparent and the root cause errors committed by high level staff such as managers and designers and result in active errors hence they reflect the safety level of the organization. Active errors are directly related to the accident in time and space as opposed to latent errors which are difficult to find (Arnstein, 1977 & Atkinson, 1998). A broader concept exists that classifies human error as genotypes and phenotypes also exist. A phenotype is defined as the gross observations that manifest due to an incorrectly performed action while a genotype refers to the causes that sufficiently explain a failed action (Hollnagel, 993; Dekker & Hollnagel, 2004). Human errors result from many factors some of which include human capabilities, task related factors and organizational factors such as management and staffing, (Skalle et al, 2013; Hale, Wilpert & Freitag, 1997). Organizational failures serve as both preconditions for human error and also exacerbate the consequences of those errors (Johnson, 1995). According to Parliamentary office of Science and Technology, 2001, mismatch between human capabilities and limitations provides insight on their interaction that leads to human error. There exists a tendency of human beings to make mistakes due to limitations in human behaviour. Human attention span can be sustained for a short time from when it becomes more prone to errors. This is compromised in a background of multiple tasks (woods, 1994) which is common in most workplaces. The work environment has challenges of perception and interpretation of information that is also responsible for human error. Logical reasoning is an important element in work environment which is important in the complex work environment to make decisions but may be hampered in the overwhelming work environment (Hollnagel, 1998). Also the undue pressure to retain information in the busy work environments limits the memory capacity in terms of storage capacity and also the ability to access the information when needed (Parliamentary office of Science and Technology, 2001). These errors can be interpreted as a breakdown in an individual’s mental process such as attention, memory, decision making among others. It is also important to consider the intention of an individual during error analysis hence the importance of distinction between Intentional and unintentional behavior in classifying human error (Reason, 1990). According to Reason, 1990, human behaviour is subdivided to three levels of performance corresponding to three error types that can occur. This is similar to Rasmussen’s (1982) categorization of human error based on the cognitive level involved. The Skill Based Performance relates to automatic behaviors based on past experiences. From this, error of Slip and Lapse can occur. Rule Based Performance results from misclassification of the situation out of unintended wrong plan and may translate to a mistake. The third level, Knowledge Based Performance is where stored knowledge is used for analytical processing; this also results in a mistake. Human errors may occur at any of the above levels with influence from the nature of workplace in terms of organization (Reason, 1990).These human errors that can occur and are discussed next include: Slip errors [commission], Lapse errors [omission], Thinking errors (include rule-based mistakes and knowledge-based mistakes and noncompliance errors (consisting of routine, situational and exceptional types of failure) among others. These error types are based on the human information processing that translates to the human various action models, further stressing the importance of cognition in causation of human error (Holnagell, 1998). Errors of commission occur when an unrelated action is carried out that hinders the achievement of the intended goal. The various errors of commission include correct actions that are executed at the wrong time, incorrect actions carried out instead of the correct actions but at the right time and thirdly, incorrect actions executed at the wrong time (Sater and Alexander, 2000). Since this occurs as part of skill-based errors which become automatic with time as the tasks become more familiar. The unintentional actions may occur at planning and execution stages accounting for these errors (Woods, 1994). For instance, it takes less of conscious effort for one to drive home through the same route daily. In this case an error would occur when one drives past the desired point without their notice. The errors result from failures of memory and/or attention. As is this scenario, lost attention to where one was heading to could have accounted for the error. Attention could be lost due to problems in visual scanning, task fixation and activation of controls inadvertently (Holnagell, 1998). Failures of memory could account for the errors of commission taking various forms as forgotten intentions, loosing steps in a sequence of events and missed steps in a checklist (Woods, 1994). More often than not, these failures have negligible effects. However, in such cases it may be fatal such as in mining industry where pedestrian proceeds into a zone with heavy vehicles forgetting to wait for radio confirmation. Just like an operator engrossed on checking ground work and activates the incorrect control. In the aircraft sector, controllers could forget to give a planned instruction (e.g. FL or heading) due to a distraction or forget to receive information leading to accidents. Other errors due to memory include forgetting traffic position due to long range observations (Holnagell, 1998). Such can culminate in delays making chances of accidents more likely. Perceptual errors also occur in skill based tasks especially in impoverished environments due to degradation of sensory input. The error lies in the misinterpretation of the input. In mining sector degradation of physical environment exists with underground operators with limited lighting presenting a fertile ground for errors. In aircraft controllers visual perception could hampered by reduced lateral and vertical separation that would require an increased visual demand that could make them fixated on potential conflicts breeding ground for human error (Reason, 1990). Errors of omission is the failure to carry out some of the actions (during a specified time period when required) necessary to achieve a desired goal. Omissions are recognized as probably the single most common human error (Reason, 1997), especially in aviation, nuclear power generation and health care procedures. Depending on the activity, the action could either have been carried out too early, too late or none at all. Considering the principle of causality, a cause exists for any failures or omissions of acts hence error of omission is both a cause and a manifestation (Holnagell, 1998). Omission could take many forms. These include skipping one or more steps in a sequence of actions, repeating previous action or reversal of a sequence of actions. Others include executing a wrong or unrelated action, executing the actions beyond sequence, premature stopping of actions and omitting the last action of a sequence. Errors of omission also accounts for imperfect self assessments as described by Caputo & Dunning, 2005, in all the five studies they analyzed there existed inability to recognize errors of omission that translates to imperfect performance evaluation. Omissions also have similar cognitive problems that predispose to their occurrence as those in error of commission such those exemplified next. It is not possible to pinpoint the specific mental process that results in omission but those task elements that likely provoke such omissions can be predicted in most cases. Short-term memory lapse can lead to failure to perform an action that is required more so if a lot of informational loading is higher placing more demands on the operator (Woods, 1994). For instance, a controller who fails to respond to a visual alert in aircraft industry or leaving a medical device in a patient after surgery due to many things to concentrate during these processes. Steps following unexpected interruptions are especially prone to omission. Interruptions also increase the likelihood of omitting several steps ahead of the actual point since the unrelated action due to interruption is unconsciously and erroneously included as part of the task sequence (Reason, 1990). Both the error of omission and commission may have different presentation with totally different consequences in each of these situations depending on time, the physical environment and other interdependent variables. Both the errors of omission and errors of commission are mutually dependent since a case of error of commission always implies an existing omission. Both errors suffer from the weakness of failing to clearly differentiate between the cause and manifestation within the error in question (Hollnagel, 2000). Thinking errors represent intentional actions that proceed as planned however the plan becomes inappropriate or inadequate for the situation. These errors are commonly experienced when performing highly structured tasks (Reason, 1990b). They are divided into rule-based mistakes and knowledge-based mistakes. When a situation fails to be recognized or is misdiagnosed leading to execution of a wrong procedure constitutes a rule-based mistake. They occur in slightly complex tasks where an individual has to look at the situation and classify it into some familiar category. These rules may be written protocols or acquired through formal training or from experience requiring recall when performing the task. If one classifies a situation wrongly then rule-based error is deemed to have occurred. For example, pressing the right switches to turn off an engine but a mistake in choosing to turn off the engine (Sater, & Alexander, 2000). On the other hand, knowledge-based mistakes are committed when an operator selects an incorrect procedure in a situation that requires choices between various actions. These occur in complex situations where one has to find answers for completely new problems by coming up with a new plan. In this case no slips occur in execution but the plan fails to yield the desired result (Hollnagel, 1998, 2000& Heinrich, 1997). This is likely in cases of time pressure, stress or inexperience. Thinking errors in general can also occur in situations where the problem is not well understood by the operators where no formal protocol exists requiring a novel solution through reasoning and thought processing demanding time and mentally concentration. This constitutes problem solving mistakes (Reason, 1990b). Non compliance errors consist of routine, situational and exceptional types of failure. They occur when operators consciously disregard established rules and regulations. Routine failure refers to situations where those in charge willingly disregard rules and regulations. These violations become a habit that is accepted as a routine (Holnagell, 1998). For instance, for a driver who often drives above the required speed a highway which seems a normal thing for many operators as there are few adverse events hence lack of a strict enforcement. These violations can be averted by notifying the authority to enforce the rules. Exceptional mistakes are isolated departures from rules and regulations; i.e. the rule is broken to perform a new task. These violations happen rarely. They are not condoned by the organization’s management nor are they indicative of any individual’s behavior. For instance, a doctor disregards regulations by performing a procedure he is not specialized in during an emergency. These are hard to correct since they happen in unpredictable manner from the normal. Situational violations occur when compliance to rules is sometimes made difficult by job pressures. This could be due to absence of appropriate equipment or adverse weather condition. Examples include using a ladder working at height rather than a scaffold, a phlebotomist using the wrong syringe to draw a blood specimen or a surgeon using the wrong size of surgical suture (Leape, 1994 & Reason, 1997). Error management is important as it is inevitable that errors will occur and comprises error reduction and error containment. Error reduction involves measures that are aimed at limiting the occurrence of errors while error containment is aimed at enhancing the detection and recovery of errors and minimizing their impact when they occur (Reason, 1997). Some of the ways to reduce action errors include the use of checklists and reminders that allows necessary steps to be carried out limiting omissions such as checklist of surgical materials post operatively. Having procedures with ‘place markers’ that one tick offs each done step also minimizes omissions. As shown by Reason, 2002, in a study of photocopying errors, using of good reminders will achieve some reduction of safety critical errors if used appropriately. Removal of distractions and interruptions that hinder cognitive process also reduces slip and lapse errors. Warnings systems and alarms to help detect action errors and can also be applied such as in air traffic control where memory and visual image limitations that can affect perception (Shorrocka & Kirwan, 2002). Other action error reduction or control methods entails human-centered design in work place (Norman, 1993) that serve to limit errors from occurring such as ensuring consistency for devices and machinese.g. up always means off, having intuitive layout of controls and instrumentation and increasing level of automation to counter errors of manual systems such as in Air traffic control where the presence of automated safety nets is necessary with increasing air traffic density (Shorrock & Kirwan, 2002). Moreover, the automated systems that aid the operator and should also be ‘informate’ i.e. gives them information to make them flexible and not machine dependent (Norman, 1993) .Most of these errors can be minimized by having highly experienced, well-trained and motivated staff. Allowing sufficient time to complete task and prevent the pressure to with its associated stresses that contribute to errors. Handling thinking errors entails planning for all relevant and possible scenarios including emergency cases and regular drills for such emergencies and mocks. Provision of organizational learning where information about unusual events is reviewed and the experiences shared to help in preventing or handling similar cases in the future (Reason, 1990b) . Improving knowledge and understanding of operator systems and training in decision making techniques which improve competency levels. Diagnostic tools and decision-making aids such as flowcharts, schematics and job-aids are also an important ways of reducing human errors (Leape, 1994). For violations that lead to non compliance errors, several system methods to curtail this exist including effective supervision, improving organizational culture such as active workforce involvement; encourage reporting of violations and punishing non-compliant acts (reason, 1989). Improving risk perception among the operators and promoting understanding and awareness of safety measures and consequences of violations such as warnings embedded within procedures helps in averting human errors. Other ways include eliminating reasons for short cuts in workplace such as poor job design, unnecessary rules, unrealistic workload and targets, unrealistic procedures and remove or counter adverse environmental factors (Manuele 2002 & Reason, 1997). To conclude, it is important to note that human error is an inevitable occurrence when undertaking various tasks. The error types are varied and can be classified using various approaches. The human failure types can fall into action, thinking or non compliance errors. The consequences can mild to severe depending on the task at hand with most adverse forms causing accidents and disasters. They can occur at various stages and may be due to individual human factors, technical and organizational factors. Understanding these factors and interrelationships human helps in implement barriers to prevent, reduce or mitigate the occurrence of potential errors. Error reduction or prevention strategies are aimed at targeting the various task stages, limitations of human abilities that predisposes to errors and learning from errors that occur. Some of these include work place design, reminders, training, and motivation among other strategies. All this will increase the coordination at the various levels, achieving individual and organizational reliability and safety with a reduction in the likelihood of accidents. References Arnstein, F. 1997. Catalogue of human error. British journal of anaesthesia, 79 (5): 645-656. Atkinson, A. 1998. Human error in the management of building projects. Construction Management & Economics, 16(3): 339-349. Busse D & Johnson C. W. Modeling Human Error within a Cognitive Theoretical Framework. In F.E. Ritter and R.M. Young (Eds.). The Second European Conference on Cognitive Modeling, Nottingham University Press, 90-97, 1998. Caputo, D. & Dunning, D. 2005. What you don’t know: The role played by errors of omission in imperfect self-assessments. Journal of Experimental Social Psychology, 41(5): 488-505. Catino M., 2010. “A multilevel model of accident analysis: The Linate disaster”, in Patrick Alvintzi and Hannes Eder (Eds.), Crisis Management, Nova Science Publishers, Inc. Feyer, A.M. & Williamson, A.M., 1998: Human factors in accident modelling. In: Stellman, J.M. (Ed.), Encyclopaedia of Occupational Health and Safety, Fourth Edition. Geneva: International Labour Organisation. Hal,e A., Wilpert B. & Freitag M. 1997. After the Event: From Accident to Organisational Learning. New York: Pergamon Press. Heinrich, H.W. (1931, 1941, 1950, 1959). Industrial accident prevention: A scientific approach. New York: McGraw Hollnagel, E. (2000). Looking for errors of omission and commission or< i> The Hunting of the Snark revisited. Reliability Engineering & System Safety, 68(2): 135-145. Hollnagel E., 1998. Cognitive reliability and error analysis method. London: Elsevier. Hollnagel, E., 1993. Human Reliability Analysis: Context and control. London: Academic Press Johnson C.W, 1995. Decision Theory And Safety-Critical Interfaces. In K. Nordby, P.H. Helmersen, D. Gilmore and S. A. Arnesen (eds.), Interact '95, Chapman and Hall, London, United Kingdom, 127-132. Leape, L.,1994. Error in medicine. Journal of the American Medical Association 272: 1851- 1857. Lucas, D., 2001. Human error prediction and controls: demonstrations made in COMAH safety cases. Proceedings of an IBC Conference on Human Error. London, February 27–28. Manuele, F.A, 2002. Heinrich revisited: Truisms or myths. Itasca, IL: National Safety Council. Manuele, F.A, 2003. On the practice of safety (3rd Ed.). New York: John Wiley & Sons National Patient Safety Agency: http://www.npsa.nhs.uk Norman D A., 1988. The psychology of everyday things. New York: Basic Books. Norman, D., 1993. Toward Human-Centered Design. Technology Review, 30: 47-53. Parliamentary office of Science and Technology, Managing Human Error, postnote Number 156, June 2001 Rasmussen, J., 1982. Human errors: A taxonomy for describing human malfunction in industrial installations. Journal of Occupational Accidents, 4, 311-333. Reason J, 1997. Managing the risks of organisational accidents. Aldershot: Ashgate. Reason J. Human error. New York: Cambridge University Press. Reason J., 1990. Human Error. Cambridge: Cambridge University Press. Reason J., 1998. How necessary steps in a task get omitted: revising old ideas to combat a persistent problem. Cognitive Technology, 3:24–32. Reason J., 2000. Human error: models and management. West J Med. 2000 June; 172(6): 393– 396. Reason J., 2002.Combating omission errors through task analysis and good reminders. Quality and Safety in Healthcare, 11(1):40-44. Reason, J.,1989. Human error. Cambridge: Cambridge University Press. Reason, P. 1990b. Human Error, Cambridge: Cambridge University Press. Sater, N. B. & Alexander H. M. 2000. Error types and related error detection mechanisms in the aviation domain: An analysis of aviation safety reporting system incident reports. International Journal of Aviation Psychology, 10(2), 189-206. SCIE: http://www.scie.org.uk Shorrocka, S. T. & Kirwan B, 2002. Development and application of a human error identification tool for air traffic control. Applied Ergonomics, 33: 319–33. Skalle P, Aamodt A & Laumann K., 2013. Integrating human related errors with technical errors to determine causes behind offshore accidents. Safety Science, 63 (2014:) 179–190. Woods D. 1994. Cognitive Demands and Activities in Dynamic Fault Management, In N. Stanton (ed.),. Human Factors of Alarm Design. London: Taylor and Francis. Read More

Active errors are directly related to the accident in time and space as opposed to latent errors which are difficult to find (Arnstein, 1977 & Atkinson, 1998). A broader concept exists that classifies human error as genotypes and phenotypes also exist. A phenotype is defined as the gross observations that manifest due to an incorrectly performed action while a genotype refers to the causes that sufficiently explain a failed action (Hollnagel, 993; Dekker & Hollnagel, 2004). Human errors result from many factors some of which include human capabilities, task related factors and organizational factors such as management and staffing, (Skalle et al, 2013; Hale, Wilpert & Freitag, 1997).

Organizational failures serve as both preconditions for human error and also exacerbate the consequences of those errors (Johnson, 1995). According to Parliamentary office of Science and Technology, 2001, mismatch between human capabilities and limitations provides insight on their interaction that leads to human error. There exists a tendency of human beings to make mistakes due to limitations in human behaviour. Human attention span can be sustained for a short time from when it becomes more prone to errors.

This is compromised in a background of multiple tasks (woods, 1994) which is common in most workplaces. The work environment has challenges of perception and interpretation of information that is also responsible for human error. Logical reasoning is an important element in work environment which is important in the complex work environment to make decisions but may be hampered in the overwhelming work environment (Hollnagel, 1998). Also the undue pressure to retain information in the busy work environments limits the memory capacity in terms of storage capacity and also the ability to access the information when needed (Parliamentary office of Science and Technology, 2001).

These errors can be interpreted as a breakdown in an individual’s mental process such as attention, memory, decision making among others. It is also important to consider the intention of an individual during error analysis hence the importance of distinction between Intentional and unintentional behavior in classifying human error (Reason, 1990). According to Reason, 1990, human behaviour is subdivided to three levels of performance corresponding to three error types that can occur. This is similar to Rasmussen’s (1982) categorization of human error based on the cognitive level involved.

The Skill Based Performance relates to automatic behaviors based on past experiences. From this, error of Slip and Lapse can occur. Rule Based Performance results from misclassification of the situation out of unintended wrong plan and may translate to a mistake. The third level, Knowledge Based Performance is where stored knowledge is used for analytical processing; this also results in a mistake. Human errors may occur at any of the above levels with influence from the nature of workplace in terms of organization (Reason, 1990).

These human errors that can occur and are discussed next include: Slip errors [commission], Lapse errors [omission], Thinking errors (include rule-based mistakes and knowledge-based mistakes and noncompliance errors (consisting of routine, situational and exceptional types of failure) among others. These error types are based on the human information processing that translates to the human various action models, further stressing the importance of cognition in causation of human error (Holnagell, 1998).

Errors of commission occur when an unrelated action is carried out that hinders the achievement of the intended goal. The various errors of commission include correct actions that are executed at the wrong time, incorrect actions carried out instead of the correct actions but at the right time and thirdly, incorrect actions executed at the wrong time (Sater and Alexander, 2000). Since this occurs as part of skill-based errors which become automatic with time as the tasks become more familiar.

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