HLST 3400 Lecture Notes - Lecture 5: Swiss Cheese Model, Chernobyl Disaster, Pharmaceutical Industry
30 May 2020
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Document Summary
The human error problem can be viewed in two ways: the person approach and the system approach. Each has its model of error causation and each model gives rise to quite different philosophies of error manage- ment. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice. The longstanding and widespread tradition of the per- son approach focuses on the unsafe acts errors and procedural violations of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharma- cists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as for- getfulness, inattention, poor motivation, carelessness, negligence, and recklessness. Naturally enough, the associated countermeasures are directed mainly at reducing unwanted variability in human behaviour. These methods include poster campaigns that appeal to people"s sense of fear, writing another procedure (or adding to existing ones), disciplinary measures, threat of litigation, retraining, naming, blaming, and shaming.
