BMJ 2000;320:768-770 ( 18 March )

Education and debate

Human error: models and management

James Reason, professor of psychology. 

Department of Psychology, University of Manchester, Manchester M13 9PL

reason@psy.man.ac.uk

The first 150 words of the full text of this article appear below.

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 management. Understanding these differences has important practical implications for coping with the ever present risk of mishaps in clinical practice.


Table Removed (Available Only in the Full Text)


    Person approach

The longstanding and widespread tradition of the person approach focuses on the unsafe acts---errors and procedural violations---of people at the sharp end: nurses, physicians, surgeons, anaesthetists, pharmacists, and the like. It views these unsafe acts as arising primarily from aberrant mental processes such as forgetfulness, 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, . . . [Full text of this article]
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