Active Failures Misperceptions of the situation Violations deviations Latent Failures Occur at the higher levels of the organization heavy workloads stressful environment - interruptions, pressures rapid organizational change incompatible goals - cost cutting vs clinical care
Capture Errors - automatic errors dialing your Mom’s phone instead of your wife’s
Capture Errors - automatic errors dialing your Mom’s phone instead of your wife’s
1) It’s a new field 2) Boundaries, Terminology, and Taxonomy 1) May seem trivial - BUT people make mistakes 2) Normal errors are inevitable 1) punitive responses rather than examine an error prone system 1) Most study cognitive science and analysis of human performance 2) We should focus on Error tolerance, recovery, and prevention
Active Failures Misperceptions of the situation Violations deviations Latent Failures Occur at the higher levels of the organization heavy workloads stressful environment - interruptions, pressures rapid organizational change incompatible goals - cost cutting vs clinical care
Cognition Skills based - foundational Rules based occurs when skills fail Knowledge based when rules fail - we fall back on knowledge