Routine violations occur when skill and experience leads someone to think the rules don’t apply to them. Several types of violation have been specified 13: Violations are not mistakes in the true sense of the word, but deviations from the prescribed best/correct way of performing a task. They are deviations from rules, protocols or norms, and always have an intentional component. Violations are a noticeably different type of aberrant behaviour. Moreover, it has been suggested that it is no longer feasible to defend a system against individual unsafe acts because the concatenation of errors likely to lead to an accident in complex systems cannot be predicted. Given that even the most competent individual will make errors from time to time, the occurrence of accidents in such systems can be regarded as normal. 11 Often, the systems are so complicated that the operator cannot be expected to have complete knowledge of what the system is doing. In the highly technical systems evident in much of modern health care, the operator is not in direct control but supervises the operation of automated processes. It is almost impossible for a system to put in place defences against all possible errors. In a complex system such as health care, slips, lapses and mistakes are inevitable. There is a tendency to go with the first solution that comes to mind, and to discount evidence that discredits our initial analysis of the situation. When the situation is totally novel, we have to devise a solution in real time and then a range of cognitive biases comes into play. When our assessment is incorrect, we may apply the wrong stored solution. This relies on a correct assessment of the situation.
Whenever possible we try to use preprogrammed solutions of the “If–Then” type. Slips and lapses happen when we execute an action sequence wrongly, whereas mistakes happen when we are in conscious control mode and successfully execute a faulty plan. However, when something novel and unexpected occurs (say, a dog runs out in the road), attention is immediately focused and we take conscious control of the situation. Routine tasks are performed automatically, freeing up attention for other tasks and allowing us to do several things at the same time (such as driving). Much of the time our performance on everyday tasks is automatic, rapid, and occurs without conscious attention. Theories of human error developed from research findings in cognitive and social psychology laboratories and from observational studies of error in everyday life 10 suggest that there are several broad types of error, or aberrant behaviour. Moreover, it is naïve to assume that all errors have the same underlying causal characteristics. Expecting errorless performance is simply unrealistic. 9 We all make mistakes, and one of the common mistakes we make is to overestimate our ability to function flawlessly, sometimes under adverse conditions-of time pressure, stress, fatigue, and conflicting demands. As an initial step it is important to acknowledge that to err is human. 7, 8 A more sophisticated approach is needed. 1– 6 In terms of health care, the Department of Health now clearly acknowledges in policy documents that the blame culture that has characterised the NHS does not contribute to the understanding and management of medical error. Over the last two decades the focus on understanding accidents in organisations has moved away from the identification of accident prone individuals, who can be blamed and weeded out, to a much more sophisticated understanding of the complexities of the interactions between individuals and systems. It is suggested that awareness of these biases, which form part of our normal thinking, should help to avoid a narrow focus on individual culpability and facilitate a more sophisticated approach to the investigation of adverse events. Examples are given of these biases, which are naturally employed in trying to understand our own behaviour and that of others, and therefore affect our understanding of adverse events. In this paper a range of cognitive biases identified by psychologists is described.
Unrealistic optimism could best be described as an full#
At the same time, a full understanding of adverse events in healthcare systems requires that distinctions are drawn between a variety of error types, each of which has different origins and demands different strategies for remediation. In the past it has sometimes been assumed in health care that all adverse events involve individual incompetence and therefore blameworthiness, an assumption that is likely to hinder the development of comprehensive and honest incident reporting systems.
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