Three Views of “Human Error”
Three Views of “Human Error”
The concept of human “error” was central to patient safety’s rise to prominence. Unfortunately healthcare developed a rather limited understanding of “error” from a complex body of work that had been evolving from different disciplines, such as psychology, sociology, and organization science. A focus on “human error” and this deficit thinking proved useful to healthcare as it was undergoing a managerial turn. The so-called “Clambake Conferences” exemplified a broad range of evolving thought about accidents and error, and the utility of the very concept of “error” became challenged.
Keywords: Three Mile Island, Tenerife, heuristics, biases, deficit model, hindsight bias, Amos Tversky, Daniel Kahneman, Charles Bosk, Marianne Paget, Marcia Millman, Donald Norman, James Reason, Charles Perrow, Gene Rochlin, high reliability, normal accidents, Swiss cheese model, Jens Rasmussen, Diane Vaughan
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