UCL Bite-sized Lecture: The Comedy of (Human) Error
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The Comedy of (Human) Error aka Being resilient to human error: Don’t end up with pie on your face! Dominic Furniss
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This mini-lecture has two objectives: 1) to raise awareness of the pervasiveness and importance of human error; 2) to give an overview of resilience strategies and introduce new concepts for thinking about this topic, i.e. a resilience repertoire, Big R and little r. These concepts are brought to life through the story of the Fray Bentos pie.
Transcript of UCL Bite-sized Lecture: The Comedy of (Human) Error
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
