The Comedy of (Human) Erroraka

Being resilient to human error: Don’t end up with pie on your face!

Dominic Furniss

Image “Robson Crane Comedy of Errors.jpg” from Wiki Commons

Funny

Frustrating

Fatal

Confusion between some models has been reported by MEDSAFE, the New Zealand Medicines and Medical Devices Safety Authority.http://www.medsafe.govt.nz/profs/device-issues.asp#Discontinuation

“The visually similar MS16A and MS26 models have a 24-fold difference in infusion rate. Confusing the two has resulted in multiple serious adverse events.”[Ref - TT05-16-2-6 (23.07.07)]http://www.medsafe.govt.nz/profs/device-issues.asp#Discontinuation

Image “Robson Crane Comedy of Errors.jpg” from Wiki Commons

#RSdiary

#RSdiary

Summary• People make errors everyday• We develop resilience strategies to reduce and

mitigate these errors• These strategies form part of our resilience

repertoire• Big R is for the stage of innovation• Little r is where strategies are shared

Acknowledgements• Prof Ann Blandford and Dr Jonathan Back • Dr Astrid Mayer, Michael Hildebrandt and Helena Broberg• Others on CHI+MED we have shared these ideas with