Transcript To Err is Human James Reason

To Err is Human
Human Factors Definition
• “Ergonomics (or Human Factors) is the scientific discipline
concerned with the understanding of interactions among
humans and other elements of a system, and the profession
that applies theory, principles, data and methods to design in
order to optimise human well-being and overall system
performance.” The Institute of Ergonomics and Human Factors (UK)
• “Enhancing clinical performance through an
understanding of the effects of teamwork, tasks,
equipment, workspace, culture, organisation on
human behaviour and abilities, and application of
that knowledge in clinical settings.” Ken Catchpole
How do we do it?
• 6 core simulations
• Emergency buzzer
• Team responds is team who stays
– MDT, all grades, within your ability
• “What would happen today if…”
• 15minute simulation in situ
• 20-25 minute debrief
Even though it was my
first day on the ward I
now know that even as
a student I have
something to
contribute
I know how to pull
the emergency buzzer
I understand that I
need to know my
environment
I Know that I am part
of a team and there
are other people to
help me
Thank you