Injury prevention human error

Leape, L. L., The Preventability of Medical Injury, in Human Error in Medicine, M. S. Bogner, Ed., Lawrence Erlbaum Associates, Hillsdale, New Jersey, 1994, pp. 13-27. 

The worst nuclear power accident in the U.S. occurred at the Three Mile Island plant in Pennsylvania. In this accident no one was killed and no one was directly injured. The event at Three Mile Island occurred from faulty instrumentation that gave erroneous readings for the reactor vessel environment. A series of equipment failures and human errors along with inadequate instrumentation allowed the reactor core to be compromised and go into a partial melt. The radioactive water that was released from the core was confined within the containment building and very little radiation was released. In the Three Mile Island incident, the safety devices worked as planned and prevented any serious injury. This accident resulted in improved procedures, instrumentation, and safety systems being implemented. 

All who undertake an inquiry to determine what additional actions may be taken to reduce serious injury potential will learn from R. B. Whittingham s The Blame Machine Why Human Error Causes Accidents. Whittingham describes how disasters and serious accidents result from recurring but potentially avoidable human errors. He shows how such errors are preventable because they result from defective systems within a company. 

Several references were made in Chapter 3, Serious Injury Prevention, to human errors as the causal factors for accidents. And it was said that many serious injuries result from recurring but potentially avoidable human errors, and that organizational, cultural, technical, and management systems deficiencies often lead to those errors. Emphasizing human error reduction above the worker level, although proposed many years ago as a preventive measure, is not prominent in the work of safety professionals. 

Safety professionals will do a better job in giving counsel on serious injury prevention if they are aware of human error causal factors. Focusing on improving management systems to meet ZIO provisions and minimizing serious injuries, this chapter ... 

Comments on the relationship between behavioral safety, human error reduction, and serious injury prevention. 

Another of James Reason s books—Managing the Risks of Organizational Accidents—is a must read for safety professionals who want an education in human error reduction. It was published in 1997 and has been reprinted five times. Reason writes about how the effects of decisions accumulate over time and become the causal factors for incidents resulting in serious injuries or damage when all the circumstances necessary for the occurrence of a major event come together. This book was referenced in Chapter 3, Serious Injury Prevention, because it stresses the need to focus on decision making above the worker level to prevent major accidents. Reason writes this ... 

BEHAVIORAL SAFETY, HUMAN ERROR REDUCTION, AND SERIOUS INJURY PREVENTION... 

The following excerpts from Reason s Managing the Risks of Organizational Accidents bear directly on the history of behavioral safety, human error reduction, and the prevention of serious injuries. 

Worker-focused behavior-based safety does not examine the sources of human error in an organization above the worker level and has limited impact on serious injury prevention. 

In Chapter 3, Serious Injury Prevention, an outline for such a study was presented under the heading Proposing a Study of Serious Injuries. Such a study will not be time-consuming since the data to be collected and analyzed should already exist or can be obtained easily. To assist in such a study, two addenda are provided at the conclusion of this chapter. Both are reprinted Ifom the third edition of On The Practice Of Safety Addendum A, A Systemic Causation Model for Hazards-Related Incidents, and Addendum B, Reference for Causal Factors and Corrective Actions. Another good reference when completing this evaluation, in terms of its comments on human errors that may be made above the worker level, is Chapter 4 here. 

But, as pointed out in Chapter 1, to claim that a certain proportion of accidents are caused by people is unenlightening. Accidents often involve both an immediate human error and a variety of engineering and system precursors. Furthermore, it is often more effective to make technical changes which will prevent accidents occurring than it is to exhort workers to behave properly. Insofar as the stress which safety leaders place on culture involves holding workers responsible for the injuries which occur to them, it is not an approach worthy of emulation. 

Wikipedia, the free online encyclopedia, defines a near miss incident as An unplanned event that did not result in injury, illness, or damage, but had the potential to do so. Only a fortunate break in the chain of events prevented an injury, fatality, or damage. Although human error is commonly an initiating event, a faulty process or system invariably permits or compounds the harm and is the focus for improvement. 

OR crisis events are often the results of unforeseen internal or external problems, and can frequently be attributed to human cognitive error or complex system safety cultures. There is seldom a single cause leading to an accident. The error chain is a concept to describe human error accidents as the result of a sequence of events that, uninterrupted may culminate in serious injury and death. The links of these error chains are identifiable by means of up to ten clues (table 1). Recognizing and breaking one link in the error chain will likely prevent the potential adverse event. 

In the first edition of Heinrich s Industrial Accident Prevention published in 1931, the causes of 50,000 accidents leading to injury and 500,000 accidents from which there were no injuries had been tallied with the following results human error 90 per cent, mechanical hazards 10 per cent. ( Human error included the following categories faulty instruction, inattention, unsafe practice, poor discipline, inability of employee, physical unfitness and mental unfitness.) In other words, the 90 per cent solution. 

In everyday situations, overlooking human factors leads to errors, frustration, alienation from technology, and, eventually, a failure to exploit the potential of people and technology. In safety-critical systems, however, such as nuclear power plants, hospitals, and aviation, the consequences can threaten the quality of hfe of virtually everyone on the planet. In the United States, for example, preventable medical errors are the eighth leading cause of death in hospitals alone, errors cause 44,000 to 98,000 deaths annually, and patient injuries cost between 17 billion and 29 billion annually (lOM, 1999). 

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