A system approach to reducing error works better than focusing on individuals

The basic premise of the systems approach to reducing error is that humans are fallible and errors are to be expected. Therefore, Reason argues on p 768, measures to reduce errors need to build defences within the systems in which humans work. Firstly, reporting of errors and near misses should be encouraged, to help identify the causes of errors. Error management then needs to aim at both limiting dangerous errors and also creating ways of limiting their effects when they do occurand often that means using humans' capacities to adapt. This combination of controlled environments and local flexibility is found in high reliability organisations that take safety very seriously, such as air traffic control centres, nuclear aircraft carriers, and nuclear power plants.

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Human error: models and management

James Reason
BMJ 2000 320: 768-770. [Extract] [Full Text] [PDF]