Combating omission errors through task analysis and good reminders.

Leaving out necessary task steps is the single most common human error type. Certain task steps possess characteristics that are more likely to provoke omissions than others, and can be identified in advance. The paper reports two studies. The first, involving a simple photocopier, established that...

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Publicado en:Quality & Safety in Health Care pp. 40 - 45
Autor principal: Reason J
Formato: pictorial tables/charts Journal Article
Publicado: BMJ Publishing Group Mar2002
Acceso en línea:Ver este registro en EBSCOhost
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        atl: Combating omission errors through task analysis and good reminders.
      aug:
        au: Reason J
        affil: Emeritus Professor Department of Psychology, University of Manchester, Manchester M 13 9PL, UK
      sug:
        subj:
          Reminder Systems
          Safety
          Task Performance and Analysis
          Treatment Errors Prevention and Control
          Copying Processes
          Organizational Efficiency
      ab: Leaving out necessary task steps is the single most common human error type. Certain task steps possess characteristics that are more likely to provoke omissions than others, and can be identified in advance. The paper reports two studies. The first, involving a simple photocopier, established that failing to remove the last page of the original is the commonest omission. This step possesses four distinct error-provoking features that combine their effects in an additive fashion. The second study examined the degree to which everyday memory aids satisfy five features of a good reminder: conspicuity, contiguity, content, context, and countability. A close correspondence was found between the percentage use of strategies and the degree to which they satisfied these five criteria. A three stage omission management programme was outlined: task analysis (identifying discrete task steps) of some safety critical activity; assessing the omission likelihood of each step; and the choice and application of a suitable reminder. Such a programme is applicable to a variety of healthcare procedures.
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        tables/charts
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    language: English
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