Error, wisdom and foresight

Dr Jane Carthey, human factors specialist, was the first speaker at the well-attended session on “Error, wisdom and foresight”, during the Association for Perioperative Practice (AfPP) Congress. Dr Carthey introduced the audience to the concept of “foresight” as a valuable tool in the armoury required by healthcare professionals in order to counter balance the likelihood of a patient safety incident occurring. She said that foresight was required so that we could identify, respond and recover from a patient safety incident. By developing skills in foresight and “error wisdom” Dr Carthey1 said that healthcare staff are more likely to recognise error-prone situations and thus intervene, minimising the opportunities for patient safety incidents to occur. The concept of foresight is described in James Reason’s article “Beyond the organisational accident: the need for ‘error wisdom’ on the frontline” which was published in Quality and Safety in Health Care (2004). James Reason’s argument is that something is required to make alarm bells ring in the heads of those confronted with situations that carry risks. Dr Carthey introduced the AfPP audience to the three buckets model.2 In the three bucket model of error likelihood, James Reason describes the probability of unsafe acts as a function of the amount of “bad stuff” in three buckets which are identified as: “the self”, “the context” and “the task”. The fuller each bucket is the more likely a healthcare professional is to commit an error or fail to recognise and respond to an unsafe situation before a patient is harmed. The “self” bucket relates to the current state of the individual involved – for example: lack of knowledge, fatigue and negative life events. The second bucket relates to the nature of “the context”, which could be distractions and interruptions, lack of time, or poor equipment. The third bucket represents the error potential of “the task”. The error potential varies widely across the different steps of a task. James Reason’s thinking came about from evidence from various industries and healthcare examples of how people had demonstrated “error wisdom” and prevented bad situations from causing harm. Even when a system sets people up to fail there are many stories where pilots, other systems operators and healthcare professionals have rescued a bad situation at the last minute or prevented something bad from happening by foreseeing and controlling the risks.

The ‘self bucket’

Table 1 shows some useful points that can be used to help see what kinds of things can go in the “self bucket”, but there may be some instances where foresight factors may sit in either the “self” or the “context” bucket. Dr Carthey introduced another concept, described by Toft and Mascie-Taylor in their paper, “Involuntary automaticity: a work-system induced risk to healthcare”.3 Involuntary automaticity is where you do not identify errors because, although you are going through the motions of carrying out a check, you are not truly consciously engaged in the checking process. This can occur even when you have double checking in place. Involuntary automaticity is a cause of checking errors where there are several independent checking processes in place, and yet a patient may still be given the incorrect drug or arrive in the wrong operating theatre. Foresight training is available to all those interested in professional development and patient safety on the National Patient Safety Agency website: www.npsa.nhs.uk Some key questions from the three buckets model are included in this training package. Readers might like to ask themselves the following questions, to further examine the three buckets model: