Following a medication error that led to the death of a patient, the nurse who administered the medication was sacked. Following an investigation by the Department of Health, no action was taken against the nurse or the hospital. However, following an anonymous complaint, another investigation found deficiencies in hospital systems and also led to the nurse being charged with criminal homicide. No disciplinary action was taken against the hospital, but the nurse was found guilty of criminally negligent homicide. This article examines the series of events and comments on the impact of this case on the health profession and patient safety.
Should you focus on behaviours?
A focus on individual behaviours is not the most effective approach to address workplace health and safety, unless all other necessary measures have been taken. Addressing behaviours should not be used to compensate for poorly-designed work or workplaces. This article outlines the importance of the Hierarchy of Controls to determine the most effective measures to address workplace health and safety, and considers the position of individual behaviours within this hierarchy.
Remembering Trevor Kletz
Trevor Kletz was a safety hero. Over a career spanning nearly 70 years, his thoughts on human factors, human error and accident investigation helped to move the industry from a focus on individual behaviour to organisational and system failures. His proposal that we should shift from blame to learning is the basis of current safety thinking.
Chernobyl: The drama
This article was prompted by the 2019 television drama series 'Chernobyl', and focuses on human error, safety culture and designing for safety. It provides some discussion points to engage with your key stakeholders and to facilitate safety moments.
12 questions to ask in an investigation
12 questions to ask in an investigation - getting behind the label of 'human error'
Human factors and Homer Simpson
What is human factors? Do you have difficulty explaining the topic to others? And what value does human factors add? This article examines the factors that might influence a control room operator's behaviour (Homer Simpson) and how we might improve his human reliability. These 'Performance Influencing Factors' are key to optimising human performance. The post provides a definition of human factors: "making it easy for Homer to do the right thing".
Human error, human performance and investigations
Human error is a central concept in ergonomics and human factors. But what is 'human error'? Is it helping us to improve safety? The language we use may be preventing us from learning or improving. In this article, I discuss a better way of thinking about human error.
Ten facts about human failure
I find these ten facts about human failure a great way to engage delegates on human factors training courses. This post also discusses Performance Influencing Factors, the things that make human failures more or less likely.
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