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(2002) argue is a more effective method of recovering
from errors than identifying problematic or
“flawed humans” (p. 140). However, in their small
study, Mitchell et al. (2016) report that poor reporting
processing, a lack of engagement on the part of
medical staff to report, poor or no feedback and
inaction on events reported, a lack of institution
level support and funding and inadequate integration
and leveraging of ever-changing health information
technology remain as barriers to effective
reporting and learning system development and
integration.
12.1.3 Error and Barriers to Safety:
The Human or the System?
In 1999, the Institute of Medicine (IOM) released
a landmark report—to Err is Human, which many
authors argue was a turning point for patient safety
in the United States and more globally [20].
Amongst many important recommendations, significant
points outlined in the report included the
fact that errors, although common and costly, can
be prevented to improve patient safety, provided
that the systems-related contributory factors to
these errors become the focus of addressing safety
issues in healthcare (IOM 1999). While many
commentators argue that there is an increased
appreciation of the systemic nature of errors in the
healthcare setting [16, 18–20] some still assert
that, unfortunately, there is a very prevalent person-centered
blame culture in high reliability organizations
such as aviation and healthcare, which to
some extent is a “psychological tendency and an
industry norm” [21]. This way of thinking and
error assignment is referred to by Reason (2000)
and Dekker (2002) as person approach, which
holds that errors occur because of unwanted
human variability and fallibility that happens in
safe system. This view of error stresses that people
working at the sharp end perform unsafe acts,
characterized by various errors and violations that
arise from abnormal cognitive processes such as
forgetfulness and inattention, which can only be
rectified by reducing human variability, setting
better boundaries through training and discipline
and possibly even naming and shaming [22, 23].
G. Dagliana et al.
In contrast, as highlighted by the IOM and
other authors [22, 23] errors can be better understood
by taking a systems approach or view. This
holds that safety is an emergent property of the
way in which a system is designed and not a
product of the action of its individual components
[21, 24]. From this perspective, errors
which occur at the sharp end, are the result of a
host of latent systemic conditions or design flaws,
or what Reason refers to as “resident pathogens”
(2000; p. 769) and active failures of people while
performing their work. Therefore, it is not necessarily
the human who causes the error (no matter
the context) but rather the human’s interactions
with the broader system (the tools, tasks, environment,
other people in a certain organizational
framework and context) which, if the system has
latent failures, result in the occurrence of error.
Woods and Cook (2002) stress that in order to
recover from error there is a need to search for
systemic vulnerabilities, while understanding
work as it is performed at the sharp end. This
enables the detection of latent failures within the
design of the system by those who operate within
in it, a critical step to informing decision-makers
on what needs to be prioritized to improve safety
and reduce the likelihood of the same thing happening
again.
Effectively, it is critical to understand whether
there is compatibility between the social side of
work (humans, their beliefs and cultures) and the
technical side of work (how it is designed organized
and actually executed). This requires an
appreciation of sociotechnical systems theory,
which is expanded below. Additionally, as articulated
in the seminal paper by Rasmussen (1997),
to effectively manage risk associated with work,
no matter the context, there is a need to consider
the various levels of stakeholders involved in the
control, regulation, and execution of work. This
is captured in Rasmussen’s Hierarchical Risk
Management Framework, which stresses the
importance of the vertical integration of knowledge
and decisions across all stakeholders
(which, in this model include Government,
Regulators, Company executives, and management
and staff at the sharp end) [25]. In other
words, knowledge and actions of how work is