Resilience in the Face of Funny, Frustrating and Fatal Human Error

Ever left your keys at home? Have you ever got in the bath with your socks on? Ever heard of surgeons leaving swabs in patients or that pilot that mistook Venus for an aircraft? Many of these trivial errors will be familiar to people. The others show that errors happen everywhere as even the most highly trained people make slips and mistakes in safety-critical situations.

We believe we can all learn more from each other’s mistakes, like understanding the tricks that people use to reduce error. These ‘tricks’ form part of an emerging area of research called ‘cognitive resilience’ (further details can be found in this paper).

At UCL we’ve been developing a website (Errordiary, www.errordiary.org) where anyone can share human errors that they come across on a daily basis. The site automatically harvests tweets including the hashtag #errordiary and site visitors can add comments. We’ve collected a wide variety of examples from typos that have left the letter L out of ‘Public Meeting’ to police officers that have shot people with live ammunition when they intended to only stun with less lethal beanbag rounds or a taser device. Errordiary can help us understand the variety of funny, frustrating and fatal errors people make and the similar psychological causes between them.

Examples

  • An example of a funny error is someone that was preparing her lunch but got her olives mixed up with her grapes. This was an unexpected culinary combination with her hummus that she’s hoping not to repeat.
  • More frustratingly the Metropolitan Police shared 1,000s of victims’ contact details with each other as the sender copied and pasted all the email addresses into the CC list rather than the BCC list, which caused a huge breach in confidentiality. As an aside, why aren’t email systems designed to warn about this confusion? I can’t imagine many situations where the sender wants to share 100s or 1,000s of email addresses with their recipients. Here, an email system that is designed to flag up suspiciously large numbers of CCed addresses could help reduce human error.
  • The fatal example is of a chemistry student who was dipping their bubble gum into some sour powder to give it a kick of flavour. The kick proved to be too much when the student mistook the sour powder for the explosive powder he was using for work, which had tragic consequences.

All three of these examples involve performing the right actions on the wrong objects. These confusions are encouraged by mundane tasks and not feeling the need to pay much attention whilst handling things that look similar.

To err is human but let’s not helplessly submit ourselves to this. People can create and apply strategies to prevent and minimise error. By reflecting on our own cognitive frailties we can create tricks to improve our performance. Everyday examples of cognitive resilience include someone leaving an umbrella by the door so it is not forgotten, or checking they have all the parts of their IKEA flat-pack furniture before they attempt to assemble it.

There are many examples resilience that are also recorded on Errordiary to complement the error posts, this time by including the hashtag #rsdiary in tweets. With others at UCL we’ve started to analyse these and have identified different types of strategy, which include strategies for not mixing things up: (1) Pre-emptive Separation is where someone separates things that might get mixed up in a task, like placing permanent markers well away from whiteboard markers to avoid mixing them up; and (2) Disambiguation involves strategies to differentiate similar things such as labelling keys on a bunch so the right one can be found easily (further details can be found in this paper).

These sorts of strategy are also used in safety-critical situations. For example, extra care is taken to make sure that John F Smith’s appendix removal isn’t confused with John A Smith’s heart op by checking their date of births and nurses draw each other’s attention to similar names when changing shifts on the ward. Also, when nurses prepare two forms of treatment at the same time they often separate the medication, their instructions and the way they perform the task to reduce the chance of confusing them (further details can be found in this paper). Like how some people check they have all the pieces of their IKEA flat pack furniture, nurses will check they have all the ‘stuff’ for treating a patient before they go to them (both are an example of a pre-commitment check). In the nurse’s case this might be complemented by a different nurse doing a formal double check too.

Resilient strategies can be seen as tricks of the trade to combat human error. They can evolve over long periods of time or in reaction to sudden changes in the workplace. Once these strategies are recognised we can make sense of them and share them more explicitly.

The emerging field of cognitive resilience aims to understand how we can guard against mistakes to make life easier and to save lives. The CHI+MED project (http://www.chi-med.ac.uk) is leading research in this area with a focus on improving patient safety through better medical device design. You can get involved by visiting Errordiary – tweet your errors and resilience strategies so we can all learn more about them and further the field of ‘cognitive resilience’.

Thanks to @jobrodie for her comments on an earlier version of this blog.

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