1. The field Guide to understanding Human Error
Sarah Gay BSN, RN
University of Indianapolis
The field Guide to understanding Human Error

2. Objectives Intro to the book and the author
Outline the key points of each chapter
How this book connects to course material
Summary
Discussion Questions
(Dekkar, 2006)

3. About The Author and His Works
This video clip gives a brief discussion of the author, his works, and a basic dialogue of this book.
Video Clip: Sidney Dekkar
(Dekkar, 2006)

4. General Overview
Showcases the ways to think about human error and the events leading up to or involved in the mishap
Gives two views of human error: The Old View and The New View
How to embrace the The New View to begin to make progress with safety and processes
“You will probe how human error is systematically connected to features of people’s tools, tasks and operational/organizational environment.”
(Dekkar, 2006)
(Dekkar, 2006)

5. Ch.1-The Bad Apple Theory
The Bad Apple Theory is The Old View at looking at human error
The basic premise of The Bad Apple theory is that complex systems usually work well, it is just some undependable people or “Bad Apples” that tend to introduce failures into the system
Singling out what one may think is “A Bad Apple” does not fix the process or the system
Adding more technology or more procedures does not always fix the process or system either
The Bad Apple Theory is generally the first line of thinking because it is cheap, easy, and it saves the public image of the entity
Example investigation: A couple of passengers died when an airliner crashed during take off. This investigation was initially looked at using The Old View, singling out the pilots. In all reality, when looking at the processes and all situations and circumstances involved, the pilots were not solely to blame. There were so many other events that occurred leading up to the crash. If the process and situations would have been taken care of sooner, the crash most likely would not have happened, and lives would not have been lost.
(Dekkar, 2006)

6. Ch.2-The New View of Human Error
The New View diagnoses trouble deep inside the complex system with human error only being a warning sign or symptom
This view of thinking states that complex systems are not basically safe; people are creating safety while negotiating multiple system goals
To understand human error there cannot be blame on a person; sources of error are structural not personal
To progress with structural safety, one has to look at the reasoning about what made sense at the time of the mishap
“The point is not to see where people went wrong, but why what they did made sense.” (Dekkar, 2006, p.19).
Example investigation: In the case of the airliner crash, all aspects have to be examined including past incidences with that plane, hardware, passengers, the flight process, others involved, runways and taxiways, control tower, weather, etc.
(Dekkar, 2006)

7. Ch. 3-The Hindsight Bias
“Hindsight means being able to look back, from the outside, on a sequence of events that led to an outcome you already know about…Hindsight allows you to pinpoint what people missed and shouldn’t have missed; what they didn’t do but should have done” (Dekkar, 2006, p.23).
Thinking about Hindsight Bias brings one back to The Bad Apple Theory and The Old View of thinking about human error
Hindsight Bias interferes with the true understanding of human error
Hindsight is everywhere, and one assumes that a bad outcome equals a bad process. Change this thinking!
(Dekkar, 2006)

8. Ch.4-Put Data in Context
Put yourself in the shoes of those whose behavior you are truly trying to understand to see what and why the decisions made sense at the time-don’t mix your reality with theirs
Behavioral data readily gets taken out of context:
Micro-matching- mismatching your world with theirs
Cherry-picking-only picking parts that only prove your reasoning in hindsight
Shopping bag of indications-Cues to what possibly happened and asking how did they miss those
Look at the data availability and the data observability
(Dekkar, 2006)

9. Ch.5-”They Should Have…”
“Lays out what counterfactual reasoning is and how it muddles your ability to understand why people did what they did. Sensitizes you to the language of counterfactuals and how it easily slips into investigations of, and countermeasures against, human error” (Dekkar, 2006).
In The New View, one has to remember that what you think should have happened cannot depict why someone did what they did-this is a fallacy
Don’t use the word “failure”-this implies you are still looking at it from an outside point of view
This makes the case for understanding human error not trying to fix what happened at this moment
(Dekkar, 2006)

10. Ch.6-Trade Indignation for Explanation
Indignation is being angry, resenting, or being annoyed with something that seems unreasonable (think road rage)
To understand The New View versus the Old View, look at the words used to give you clues if you are on the right track or not
The “shoulda, coulda, woulda” words need to be reassessed
The New View uses language of understanding and explanation
(Dekkar, 2006)

11. Ch.7-Sharp or Blunt End?
“Reactions to failure focus firstly and predominately on those people who were closest to producing or potentially avoiding the mishap. It is easy to see these people as the engine of action. If it were not for them, the trouble would not have occurred” (Dekkar, 2006, p.59).
This again is The Old View thinking
To avert this think in terms of sharp and blunt ends of an object:
The sharp end are those in direct contact with the safety process-pilots, surgeons, train cab…
The blunt end is the organization that supports the activities of the sharp end-airline, hospital, shipping company…
Don’t look for sources of failure FAR from the sharp end
Look at failure as an opportunity to learn
(Dekkar, 2006)

12. Ch.8-You Can’t Count Error
This basically sums it up- getting a hold of the human error issue does not equate to quantifying it
One has to look in the head of the one making the errors and in the world in which the error was made
To truly understand, one must embrace The New View and stop asking the questions of human error versus mechanical failure-there is more to it
(Dekkar, 2006)

13. Ch.9-Cause is Something You Construct
“Talks about the difficulty of pinpointing the cause (proximal or root or probable cause) of an accident. Asking what is the cause, is just as bizarre as asking what is the cause of not having an accident. Accidents have their basis in the real complexity of the system, not their apparent simplicity” (Dekkar, 2006).
There is no single cause of an error
There is no distinction between human error and mechanical failure-there is complexity involved and lines get blurred
Sometimes you have to come up with an actual designated “probable cause,” but this does not allow for the blurred lines and becomes fallible
(Dekkar, 2006)

14. Ch.10-What is Your Accident Model?
There are three different models to looking for causes of mishaps in safety:
The sequence-of-events model—accidents are a chain of events leading to a failure
The epidemiological model-accidents relate to hidden failures that don’t come out unless provoked by other factors
The systemic model-accidents occur from interactions between the system and processes, not from within (working toward perfection without time, resources, money…)
(Dekkar, 2006)

15. Ch.11-Human Factors Data
Though we are thinking of the issues in process and systems, we are also thinking about human factors and what lives/jobs were and are impacted
Human error isn’t only about humans-it is about how features of the tools and tasks and working environment of the people systematically influence the human performance
There can be a lack of data and a lack of resources when it comes to reporting data
No one really wants the fault to be on them and sometimes don’t want to see where they went wrong-denial
(Dekkar, 2006)

16. Ch.12-Build a Timeline
A timeline is a powerful tool to use to understand the steps in human error
You have to connect behavior and process over time-what was going on around the people at the time of the incident?
Identify the events in your timeline data
“Your timeline should be of maximum possible resolution to reveal human performance issues,” (Dekkar, 2006, p.101).
(Dekkar, 2006)

17. Ch.13-Leave a Trace
When dealing with and writing up a situation, labels are underspecified and again lines can be blurred and blame can be cast-goes back to The Old View
Don’t take leaps of faith on situations, make sure data or factual information is given
“The interesting cognitive and coordinative dynamics take place beneath the large psychological label. The label itself explains nothing,” (Dekkar, 2006, p.122).
Example investigation: Trying to cause out the airplane example- “Loss of effective Crew Resource Management” ‘caused’ the crash-this explains nothing of the process and implications involved. The process is underneath this label.
(Dekkar, 2006)

18. Ch.14-So What Went Wrong?
There has to be dynamic fault management and planned continuation to look at all of the specific factors.
The New View maintains that people are the only ones that can can build the framework for the technologies introduced
Have to adapt to procedural changes that advance the safety and process
“Offers alternative to ‘human error’, explaining human performance issues such as breakdowns in coordination, cognitive lock-up, automation surprises, plan continuation, distortion of time perception under stress, and buggy or inert knowledge” (Dekkar, 2006).
(Dekkar, 2006)

19. Ch.15-Look into the Organization
Do exactly that-look into the organization and understand that human error problem is an organizational problem because human error is largely created by the organization
When looking at improving the process compare and contrast work in the ideal state versus the reality state
When developing a safety culture:
Look at the commitment of management
Look at the involvement of management
Look at employee empowerment
Look at the incentive structures
Look at the reporting systems
(Dekkar, 2006)

20. Ch.16-Writing Recommendations
“Efforts to understand human error should ultimately point to changes that will truly remove the error potential from a system-something that places a high premium on meaningful recommendations,” (Dekkar, 2006, p.173).
Keep goals and recommendations SMART
Specific
Measurable
Agreed
Realistic
Time-bound
This ultimately relates to the continuous quality improvement of your organization!
(Dekkar, 2006)

21. Ch.17-Abandon the Fallacy of a Quick Fix
Human error is complex and part of a complex system or organization
All quick fixes are fallacies including retraining, reprimanding, and rewriting procedure
Do not compartmentalize the people or the error and by no means fall under the blanket statement “to err is human”-though this may be correct, this normalizes errors and thwarts efforts to fix the issues and processes
Have the confidence that the system can get better and safer-use failure as motivation and opportunity to improve
(Dekkar, 2006)

22. Ch.18-What About People’s Own Responsibility?
Yes people have to be responsible and take accountability, but this also means that there has to be proof of authority-someone has to take the reigns to fix this issue
The Old View does not take responsibility where The New View does
Hold people accountable for their actions when necessary-yes-but let them tell their story and then try to figure out the process and what caused the error
(Dekkar, 2006)

23. Ch.19-Making Your Safety Department Work
A good safety department is informed, independent, informative, and involved
Make sure there is proper feedback for systems and individuals
Find personal and systemic shortcomings that can be improved
(Dekkar, 2006)

24. Ch.20-How to Adopt the New View
Embracing The New View is not an on-off switch-it takes work and practice
Growth towards The New View is not even-not all parts of the system or organization learn at the same pace or level
Growth towards The New View is not regular-there are times that are slow and regression to The Old View can occur, but push through especially during times of acceleration and change
Crisis-paralysis of The Old View
Disassembling Old View interpretations
Freezing Old View countermeasures
Understanding that people create safety through practice
New View investments and countermeasures
Learning how you are learning from failure
(Dekkar, 2006)

25. Ch.21-Reminders for in the Rubble
This sums up the most important factors in the book and lists areas of interest
Your Organization and Roots of Error
What to Think of when Investigating Human Error
Doing Something About Your Human Error Problem
Recognizing Old View Thinking
Creating Progress of Safety with The New View
(Dekkar, 2006)

26. Conclusion
All in all this books gives the guidelines and tools necessary to evolve from The Old View of thinking about human error to The New View of thinking and why it is important. It drives home many of the same points over and over to keep them at the forefront of your thinking. Basically it is the process and the organization that needs to be looked at as a whole, not just a few Bad Apples.
(Dekkar, 2006)

27. How This Relates to Quality Improvement
This book presents the effectiveness of the tools and approaches that are the fundamentals of CQI while looking at processes and human error
It explains underlying philosophy of CQI and can easily be related to healthcare.
According to Sollecito (2013), “CQI is further distinguished by its emphasis on avoiding personal blame. The focus is on managerial and professional processes associated with a specific outcome-that is, the entire production system,” (p.9).
(Dekkar, 2006)

28. Discussion Questions
Dekkar brings up the topic of Nature vs. Nurture in this book. Is human failure part of our nature solely, or is it a result of nurture?
In your organization have there been occurrences where The Old View of thinking has been applied versus The New View? What were the outcomes?
When looking at error and trying to define an “Accident Model” (Ch.10) what do you believe is the best place to start and what model would you choose?
(Dekkar, 2006)

29. References
Dekkar, S. (2006). The Field Guide to Understanding Human Error. Ashgate Publishing Company Brookfield, VT.
Sollecito, W. A. & Johnson, J. K. (2013) McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care. (4th Edition) Jones and Bartlett Publishers: Boston.
(Dekkar, 2006)