Human error: models and management

doi:10.1136/bmj.320.7237.768

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James Reason (reason@psy.man.ac.uk), professor of psychology.

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

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.

Summary points

Two approaches to the problem of human fallibility exist: the person and the system approaches

The person approach focuses on the errors of individuals, blaming them for forgetfulness, inattention, or moral weakness

The system approach concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects

High reliability organisations—which have less than their fair share of accidents—recognise that human variability is a force to harness in averting errors, but they work hard to focus that variability and are constantly preoccupied with the possibility of failure

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, naming, blaming, and shaming. Followers of this approach tend to treat errors as moral issues, assuming that bad things happen to bad people—what psychologists have called the just world hypothesis.1

System approach

The basic premise in the system approach is that humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as …