UCL Bite-sized Lecture: The Comedy of (Human) Error
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This mini-lecture has two objectives: 1) to raise awareness of the pervasiveness and importance of human error; 2) to give an overview of resilience strategies and introduce new concepts for thinking about this topic, i.e. a resilience repertoire, Big R and little r. These concepts are brought to life through the story of the Fray Bentos pie.
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UCL Bite-sized Lecture: The Comedy of (Human) Error
- 1. The Comedy of (Human) Error aka Being resilient to human error: Don’t end up with pie on your face! Dominic Furniss
- 2. Image “Robson Crane Comedy of Errors.jpg” from Wiki Commons
- 5. Confusion between some models has been reported by MEDSAFE, the New Zealand Medicines and Medical Devices Safety Authority. http://www.medsafe.govt.nz/profs/device-issues.asp#Discontinuation “The visually similar MS16A and MS26 models have a 24-fold difference in infusion rate. Confusing the two has resulted in multiple serious adverse events.” [Ref - TT05-16-2-6 (23.07.07)] http://www.medsafe.govt.nz/profs/device- issues.asp#Discontinuation
- 7. Image “Robson Crane Comedy of Errors.jpg” from Wiki Commons
- 9. #RSdiary
- 10. #RSdiary
- 13. Summary • People make errors everyday • We develop resilience strategies to reduce and mitigate these errors • These strategies form part of our resilience repertoire • Big R is for the stage of innovation • Little r is where strategies are shared
- 14. Acknowledgements • Prof Ann Blandford and Dr Jonathan Back • Dr Astrid Mayer, Michael Hildebrandt and Helena Broberg • Others on CHI+MED we have shared these ideas with
Notas del editor
- Say a bit about Me, CHI+MED and my role within it.The two themes that I want to talk about today are human error and resilience strategies to reduce human error.I hope to raise awareness of the importance and pervasiveness of human error.I hope to provide you with concepts and a vocabulary to start thinking about resilience more deeply.
- “Comedy of Errors” is believed to be one of Shakespear’s first plays. The story involves the mistaken identity of twins, which leads to a number of unfortunate errors as their lives mistakenly entwine.The story that I want to tell in this mini-lecture is also about another pairing – human error and resilience. The first looks at our cognitive limitations and how we are susceptible to imperfect actions – mainly due to our limited ability to remember things, our limited focus of attention and our limited working memory. The second involves the development of strategies to try to compensate for our cognitive frailties, to reduce risk and improve our performance.Like other good stories we will brush on some of those core human elements that colour our world: laughs, drama, tragedy and romance!
- So the first thing we’re going to look at is the pervasiveness of human error, and the stupid things that we do everyday. This could be mistyping a phone number, it could be pouring orange juice into your cereal bowl rather than pouring the milk, it might be putting a red sock in with your whites, or it might be going to work with different shoes on. Hopefully you’ll be able to relate to some of these.These examples are all in fact inspired by Errordiary. www.errordiary.org is a website that we have developed that collates people’s funny, frustrating and fatal errors. People can tweet with the hashtag #errrodiary and it will appear on the website. For some reason people find it attractive to share their errors and the silly things they do, also the media love to report on accidents and often use ‘human error’ as the cause of the accident. At UCLIC we use this site for teaching people about the psychology of human error as students are challenged to analyse and categorise them these real errors.I think one of the important things about Errordiary is that it demonstrates the pervasiveness of human error, and that the same psychological principles underlie funny, frustrating and fatal human error. We probably all acknowledge that we make silly mistakes around the home, e.g. like getting into the shower with our knickers on or searching high and low for your glasses only to find you’re wearing them… people that go to work do these things, and people doing safety critical work like pilots, nurses and doctors will also do these things. We do not suddenly become superhuman just because we’re in a different context.
- So here I’ve selected three Errordiary entries to demonstrate the link between funny, frustrating and fatal events. All of these entries involve activating some practiced routine but doing the right routine on the wrong object.For example the first involves putting grapes on hummus instead of olives… the nice thing here is the person had anticipated the threat but didn’t act on reducing the risk.The second involves someone copying 100’s of emails into the cc field and not the bcc field, and so they mistakenly shared victims’ emails with each other (as an aside why doesn’t the email programme warn the user of this happening… when do you ever want 100’s of recipients to see everyone else’s emails??)The third is a chemistry student that was chewing gum, instead of dipping it in the bowl of sour powder for an extra kick of flavour they dipped it in the bowl of explosive powder that looked similar and blew their jaw off.So we can analyse these errors and at least at some level start to see the seriousness of our psychology misfiring and messing up.So is this a problem for patient safety? Well yes, human error is critical to patient safety… not just for pulling patients through, but also for not causing them more harm when they are in care.
- This is a picture of a subcutaneous infusion pump. This model works in mm/hr. It’s sister model is green with a big 24 instead of a 1, and works in mm/24hrs. As we can see from the New Zealand Medical Device Authority… clinicians have confused the two. We might think… wait a minute, if one is blue with a 1, and the other is green with a 24, then how could you mix them up? But think back to the grapes, the bcc field and the exploding gum!The national patient safety association have also released RRR 19 which includes clinicians confusing hr and 24hr in calculations, and mm and ml in calculations… which has resulted in at least 21 incidents of patient harm over about a 5 year period:Rapid Response Report NPSA/2010/RRR019 /// National Learning and Reporting System /// 01 Jan 05 – 30 June 10IssueIncidentshrVs 24hrs 14mm Vs ml 7Potential confusion between:mm / hr, mm / 24hr,ml / hr,ml / 24hr
- I observed this recently on a crash trolley in hospital… is this enough? Think back to the grapes, the bcc field and the exploding gum!This is part of ongoing work that I need to talk to nurses more about.
- So the second half of this talk is looking at resilience which can almost be the flipside of human error… e.g. instead of submitting ourselves helplessly to the fact that we are susceptible to human error because of our cognitive frailties, resilience proactively develops strategies to avoid, recover from and mitigate the effects of errors. So how about some examples…
- Do you leave an umbrella or similar by the door? Usually we acknowledge the risk of forgetting the item so we put in by the door so we almost have to trip over it to get out.Another example from a study at UCLIC are the micro-strategies used to remember your chip and pin cards, e.g. some people keep their wallet out, some people keep hold of the card, some people pause other tasks so they are not distracted and forget that their card is there. [again as an aside we can think of designs that can help with this issue… e.g. the receipt does not print and so the transaction can’t be completed until the card is removed].
- So, we also have a place on Errordiary where people can share their resilient strategies but this time you need to use the hashtag #rsdiary.Co-locate something that you are trying to remember with something that you must use…Create an external cue in the environment to off load memory tasks… I’ve never breast fed a baby but I have it on good authority that you’re fairly sleep deprived and stressed so remembering what boob is next at 4am when you’ve had no sleep, been changing nappies and have a baby screaming in your ear it is not the easiest thing to do.
- I bought some jumpers a while back that need to be cold washed… I perceived the risk of getting these mixed up with the normal wash so I thought I’d put a plastic bag in my laundry basket so separate them on the point of entry rather than leaving them mixed, increasing the likelihood of me forgetting.Someone has commented on this one! And is going to use it. ‘Little r’So now we’re starting to engage with resilience strategies I want to introduce some more concepts that help think about them in more detail.Resilience repertoire – this is a range of resilience strategies that we have that we can useBig R – innovation and the moment of creationLittle r – adopting, adapting and sharingSo I want to bring these concepts to life in a the story of the Fray Bentos pie. So we have laughs in the funny errors, we have had deaths in the fatalities and now this is the romance (as promised).
- Has anyone come across these? The Fray Bentos pie. They have a bit of a cult following and although some might frown upon the filling, others find comfort in their crispy golden crusts.Tell them what you do to prepare the pie for consumption: remove lid and cooking instructions.One evening when I was at University in Warwick my girlfriend and I were settling in for a romantic meal (a bit like the picture except without the candles, champagne and chianti) and disaster nearly struck! She had removed the lid of the tin as instructed but now needed to know the next step… however, can you see a problem with the tin? Yes, the instruction are on the bottom. Without thinking she went to raise my open tin above her head but I shouted over to stop her. I did this because 1) I did not want my dinner all over the floor, and 2) I did not want an angry girlfriend with pie on her face. I thought there must be a better way …… then it hit me! We had some spare ones in the cupboard. I said to put down the open tin, and we got a spare one from the cupboard to access the rest of the instructions safely. I had saved the day and we both enjoyed the rest of the evening. [Big R – creating the resilience strategy]Another interesting part to this story: The next week the same thing happened, but without any intervention from me or even an extra batter of her eyelid from my girlfriend she retrieved a spare tin from the cupboard to access the instructions risk free. [little r – an existing resilience strategy is adopted or adapted]This strategy had become part of our resilience repertoire, and hopefully, if you choose to indulge in the delights of Fray Bentos you can use it too.
- So going back to my day job, how can this help with understanding professionals work?Well people develop resilience strategies at work too… i.e. strategies that are created and adopted outside formal procedures that help people avoid error and improve their performance.I recently moved in with my girlfriend and we bought a chest of draws from IKEA that needed assembling. I proposed we do it one evening and she reluctantly agreed, and I had an important realisation as she stomped upstairs with tools in her hand exclaiming, “I hate flat pack!”. This is even before we’ve opened the box! Anyway, I realised that my primary goal was not the obvious one: to assemble the furniture correctly, but instead it was an indirect goal: to try and keep our relationship together. It was the first real test we’ve had, we came through the other side, and I think we’re stronger for it.Anyway, we found that a good strategy when assembling this furniture was to count all the pieces and group them to make sure that we had all and only the right bits needed for the assembly. This saves nasty surprised at the end when you have an extra bit or perhaps you find you are missing a bit part way through. Nurses do something similar when preparing treatments for patients and they tend to use trolleys and trays as units of work to prepare all and only those bits they need for the treatment, we think this is so they can monitor for error better – a bit like IKEA furniture.If we recognise more of these resilience strategies, tricks of the trade, and best practices we can make sure they are protected and shared to improve practice more broadly.
- Whilst preparing for the bite-sized lecture I came across the Bentos bite-sized pie… amazing!