Error management participants

The Critical Decision Method, as adapted for this study, involves an interview of approximately one-hour duration for each participant. The interview proper was broken into three major sections, with the Critical Decision Method being used three times to ejqrlore different aspects of the management of error in normal operations as well as training. The three sections of the interview were broadly 1) the management of shps and lapses 2) the management of mistakes and 3) error management from an instructional perspective. 

As discussed earlier in this chapter, the main requirements to ensure an appropriate safety culture are similar to those which are advocated in quality management systems. These include active participation by the workforce in error and safety management initiatives, a blame-free culture which fosters the free flow of information, and an explicit policy which ensures that safety considerations will always be primary. In addition both operations and management staff need feedback which indicates that participation in error reduction programs has a real impact on the way in which the plant is operated and systems are designed. 

In addition to the management level factors which can be specifically linked to operational level factors (procedures, training, and design), the HFAM tool also provides an assessment of other management level factors which will impact upon error likelihood in a less direct way. Some of these factors, for example, "safety priorities" and "degree of participation," are... 

The type of data collected on human error and the ways in which these data are used for accident prevention will vary depending upon the model of error and accident causation held by the management of an organization. This model will also influence the culture in the plant and the willingness of personnel to participate in data collection activities. In Chapters 1 and 2 a number of alternative viewpoints or models of human error were described. These models will now be briefly reviewed and their implications for the treatment of human error in the process industry will be discussed. 

Three major themes have been emphasized in this chapter. The first is that an effective data collection system is one of the most powerful tools available to minimize human error. Second, data collection systems must adequately address underlying causes. Merely tabulating accidents in terms of their surface similarities, or using inadequate causal descriptions such as "process worker failed to follow procedures" is not sufficient to develop effective remedial strategies. Finally, a successful data collection and incident investigation system requires an enlightened, systems oriented view of human error to be held by management, and participation and commitment from the workforce. 

Employee training, empowerment, and participation In world-class quality organizations, employees are partners with management in making decisions about how work is done. People are empowered with the right training, tools, techniques, and authority to deliver error and... 

Patients contribute to their own care at every stage through provision of diagnostic information, participation in treatment decisions, choice of provider, the management and treatment of disease and the monitoring of adverse events and other ways (Box 15.2) (Vincent and Coulter, 2002 Coulter and Filins, 2007). Patients also need to actively intervene to protect themselves from errors or to avoid delays for instance, patients frequently provide repeat histories to compensate for missing notes, relay information between clinicians, remind nurses of tests that should be done and chase test results. Unruh and Pratt (2007) nicely describe this as the invisible work that patients do in a healthcare system and provide some apposite examples of the ways in which cancer patients monitor and actively intervene to ensure they receive the correct treatments (Box 15.3). 

Many factors have been highlighted as supporting the development of an effective patient safety culture. Some of the important ones are management (i.e., management commitment, ability, leadership, coordination, and flexibility), immediate supervisors (i.e., open-door policy, participation, and support correct behavior), reporting system (i.e., reporting near-miss, no-blame culture, analysis of error, open-door policy, confidentiality, and feedback). 

Angermeier, I., Dunford, B., Boss, A. D., Boss, R. W., The Impact of Participative Management Perceptions on Customer Service, Medical Errors, Burnout, and Turnover Intentions, Journal of Healthcare Matmgement, Vol. 15, No. 2, 2009, pp. 127-141. 

One element of safety management is to look at the behavior of employees and the organizational culture. Everyone has a responsibility for safety and should participate in management system efforts. Modern organization safety has progressed from safety by compliance to a more appropriate concept of prevention by planning. Reliance on compliance could translate to after-the-fact hazard detection that does not identify organizational errors that are often the contributors to incidents [5]. 

FMS s 2-day intensive medical TRM program introduces team members to the basic concepts of human performance, as used by the aviation industry in its attempts to understand and prevent crew errors, incidents and accidents. Using a variety of actual airline accident and medical incident case studies, program participants will learn about crew resomce management principles, and how CRM training has achieved positive safety results within the international airhne industry. 

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