HF300: Human Error

Reminder about Quiz 7
- Due date: This morning.
- High scoring, great job to everyone.
- Review of answers scheduled for Tuesday’s lecture.
Design Day Overview
- Reminder for presentations of decision choices.
- Lighter lecture with a focus on design presentation.
Exam 3 Information
- Scheduled for one week from Thursday; not cumulative.
- Study guide available on Canvas, complete resource based on materials since Exam 2.
Project Submissions
- Due date: December 2 at 5 PM.
- Submit via Canvas to avoid last-minute confusion.
Extra Credit Information
- Due by December 4 at 9:30 AM, before Exam 3.
Human Factors related articles
- Send article topics for review if unsure about relevance.
- Recommendations: Check the Human Factors Journal.
Presentation Slides Submission
- Due by the Monday before design day, 24 hours in advance.

Context of the Lecture
- Last lecture of the semester focusing on the concept of human error.
- Importance of defining and understanding human error based on definitions from different sources.

Variability in Definitions
- No universally accepted definition as of 2025.
- Common components across definitions: failure to achieve desired outcomes, inappropriate or undesirable behavior affecting effectiveness or safety.
Preferred Definitions
- Human error is defined as actions that reduce or potentially reduce effectiveness, safety, or performance.
- Also defined as actions outside the bounds of expected acceptable performance in a specific situation.
Notable Aspects
- Error occurrence does not always require adverse consequences; an error can exist without visible outcomes.

Human error classification based on two primary sources:
- Causation of problems created by the error.
- Situational consequences from errors.
Example Scenarios
- Nurse misreads a medication label (error leading to wrong dosage).
- A worker makes errors due to fatigue or stress.
Quote by James Reason on Human Error
- "Bad design is often the culprit of human error."
- Example: Issues in flight deck design leading to operational errors (gear vs. flaps).

Training alone cannot eliminate human error.
- Highly trained professionals can still make errors.
Importance of recognizing human limitations:
1. Experienced doctors can make medical errors.
2. Experienced pilots can still cause accidents.
3. Drivers make mistakes despite proper education and experience.

Errors of Omission
- Definition: Fail to perform intended actions.
- Example: Forgetting to sign a quiz.
Errors of Commission
- Definition: Incorrect action taken, performing an action incorrectly.
- Example: Pressing the addition button instead of subtraction on a calculator.

Slips
- Error during an intended action execution, i.e., doing the wrong thing.
- Example: Opening the camera app instead of calculator.
Lapses
- Memory-related failures; forgetting to execute intended actions.
- Example: Forgetting a scheduled doctor's appointment.
Mistakes
- An error in reasoning; wrong intention or flawed understanding of circumstances.
- Example: Mistaking oven temperature for baking.

Skill-Based Errors
- Highly automated behavioral mistakes, executed unconsciously.
- Example: Experienced nurse administering wrong medication due to automatic behavior.
Rule-Based Errors
- Application of the wrong rule or guideline to a situation.
- Example: Inappropriate extubation actions by health professionals.
Knowledge-Based Errors
- Errors deriving from unfamiliar situations requiring conscious thought and independent decision making.
- Example: Prescribing a new medication without knowledge.

Accidents: Unanticipated events leading to consequences (serious injury, equipment damage).
- Definition example (aviation): Injury or damage occurring from the start of boarding to disembarkation from flight.
Near Misses: Instances where an accident almost occurs but is avoided.
- Example: Slamming on brakes to avoid hitting another car.
Violations: Intentional errors that might lead to consequences.
- Two major types: routine violations (habitual rule bending) and exceptional violations (rare, not condoned).

Stress and Workload Factors: Increasing stress levels elevate potential for errors.
Error Detection and Prevention: Importance of monitoring work environments and reporting systems.
- Example: Aviation safety reporting system for error reporting.
Error Correction Strategies:
- Fostering a supportive culture allows for effective error reporting without punishment.
- Use of team performance monitoring among colleagues.

Concept of defense layers to prevent accidents; layers (like cheese) have weaknesses (holes).
The more weak defenses present, the higher chance errors will pass through all layers leading to accidents.

Need for understanding human error in practical applications and future careers.
Importance of communication, teamwork, and training in error reduction.

Individual analysis of scenarios on types of errors (omission vs. commission, slips vs. mistakes).
Group collaboration for discussing scenarios and arriving at consensus answers.
Key assessment points:
- Applying definitions to real-world scenarios.
- Noting distinctions between types of errors as per classifications discussed in lecture.