Slip/lapse errors

It is easy to see how the approach can be used to identify what the risk assessment team consider important controls which have or have not been considered in the design. Actions can then be placed to ensure additional measures are taken during the design process. It is also evident from this example how what is essentially a slip/lapse error (that is, accidental activation) has been (correctly) addressed largely by design details which will reduce the likelihood of the error occurring. Equally, it can be readily appreciated how such an approach will reduce the opportunity for designed-in error potential. 

Decide that as Fred was directly responsible he shonldbe disciplined (or even sacked). However, while sacking Fred may stop him making the same mistake again, it is nnlikely to stop anyone else (in fact, dependent on the error it may have no impact at all, particnlarly if it was a slip/lapse error). 

Human error is defined by James Reason as the failure of planned actions to achieve their desired ends - without the interveution of some unforeseeable event [1]. Depending on the mode in which we are performing, different types of errors might occur. These are often referred to as slips, lapses and mistakes. 

The study of patient safety is the study of complexity. The study of complexity invites us to understand key concepts that can be applied to patient safety. Basic concepts from the fleld of patient safety are sharp and blunt end active and latent failure the Swiss Cheese Model of Accident Causation slips, lapses, and mistakes and hindsight bias and the fundamental attribution error. Key concepts from organizational analysis, such as normalization of deviance, diffusion of responsibility, tightly coupled work processes, and sensemaking, introduce practical lessons from high-reliability organizations. Application of specific lessons to health care are explored in Chapter Five. 

Reason s approach to human frailties is probably die most well-known approach with two major categories of behaviors being considered unintentional errors such as slips, lapses, mistakes and the noncompliance with work rules and procedures (Reason, 1990, 1998). 

Human errors fall into three groups - slips, lapses and mistakes, which can be further sub-divided into rule-based and knowledge-based mistakes. 

The key to normal operations data is to collect it in a non jeopardy, de-identified manner. Non jeopardy is not immunity I say again - non jeopardy is not immunity The data collected are all in terms of the threat and air management stractme. Threats are external to the individual. Errors are internal, made by the individual. Individuals do not see or report most of the threats that they deal with because they deal with them daily. Example weather if it is 120 degrees on the ramp or if it is minus 20 with ice and snow, the bags still need to be loaded, the engine still needs to be fixed and the crew still needs to do a walk aroimd inspection. Most do not see the weather as a threat they see it as just another lousy day. Mistakes, slips, lapses, commissions, omissions, and other unintentional errors, on the other hand most likely go unreported due to fear of punishment or simply embarrassment. 

Unsafe act (SA) - an error (slip, lapse, or mistake) or deliberate deviation from prescribed operating procedures, which, in the presence of a potential unsafe condition, leads to an occurrence or creates occurrence potential ... 

These are the eirors or violations that led directly to the incident. They are typically associated with personnel having direct contact with the equipment, such as operators or maintenance personnel. They are always committed actively (someone did or did not do something) and have a direct relation with the incident. For most of the time, however, the defences built into our operations prevent these human errors from causing harm. Individual/team actions within the ICAM model are initially categorized into intended or unintended actions and then categorized as slips, lapses, mistakes or violations. 

The most commonly referred to error classification within the literature, however, is the slips, lapses, mistakes, and violations classification proposed by Reason (1990), an overview of which is presented below. 

In addition to the simplistic slips, lapses, mistakes, and violations classification described above, further error types have been specified within each category for example. Reason (1990) proposed a taxonomy of nnsafe acts that identifies a number of different error types within each of these fom error categories. The taxonomy of unsafe acts is presented in Figme 14.1. 

Errors are actions or decisions which were not intended and which involved a deviation from an accepted standard, rule or procedure. They can be divided into slips, lapses and mistakes. 

It is worth noting, here, that this categorisation and plication of attributes relates primarily to Reason s behavioural and contextual levels of human error classification (i.e. it indicates the fiictors likely to lead to errors of a particular type (slips, lapses or mistakes)), but does not address the conceptual level of error classification, which is concerned with cognitive mechanisms involved in error production. 

Slips (execution errors) and lapses (memory errors) occur at the skill-based performance levels. They are due to the intrinsic variability of human actions with respect to place, force and time co-ordination. 

The slip/lapse-mistake-violation classification can be particularly useful in relation to identifying appropriate mitigation. The introduction of violations as a unique category is also of considerable importance in gaining a comprehensive classification of error type. This classification also has the advantage that the descriptors used are used in a way which is entirely consistent with their everyday meaning. 

It has become widely accepted that the most comprehensive and useful human error classification is a combination of the Rasmussen skill, rale and knowledge structure with Reason s slip/lapse, mistake and violations (for example, ACSNI, 1991, 1993). The combination most commonly cited is as follows ... 

Classify each of the potentially safety critical human errors which remain on the candidate list using, for example, the slips/lapse-mistake-violation classification (or other classifications, if preferred). 

Type of error - slip/lapse Preferred route to solution - design... 

This chapter describes accidents caused by those slips and lapses of attention that even well-trained and well-motivated persons make from time to time. For example, they forget to close a valve or close the wrong valve. They know what they should do, want to do it, and are physically and mentally capable of doing it. But they forget to do it. Exhortation, punishment, or further training will have no effect. We must either accept an occasional error or change the work situation so as to remove the opportunities for error or to make errors less likely. 

When an accident report says that an accident was due to human error, the writer usually means an error by an operator or other front line worker. But designers and managers also make errors, not slips or lapses of attention as they usually have time to check their work, as well as mistakes or, less often, violations. 

Because no individual knows everything, and because everyone has occasional slips or lapses in performance, everyone makes errors. Medication use is a complex process that consists of subprocesses such as the ordering, preparing, dispensing, administration, and the provision of patient education. 

The medicahon use system can be divided into five areas selecting, ordering, dispensing, administering and monitoring. Error potenhal is prevalent in each area. Some causes of errors transcend segments of the medicahon use system and occur in two or more phases. In particular, violations of rules and slips, or memory lapses, are seen in each of the five areas of the medication use system. 

Here we discuss the concepts of error and uncertainty. In the world the word error implies a failure of some kind—synonyms include mistake, blunder, slip, and lapse. In metrology, error is defined as the result of a measurement minus a true value of the measurand and is free of such negative connotations. Error in an analysis is a particular value that may be known if the true value is given. 

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