Human error theory: relevance to nurse management.

AIM: Describe, discuss and critically appraise human error theory and consider its relevance for nurse managers.

BACKGROUND: Healthcare errors are a persistent threat to patient safety. Effective risk management and clinical governance depends on understanding the nature of error.

EVALUATION: This paper draws upon a wide literature from published works, largely from the field of cognitive psychology and human factors. Although the content of this paper is pertinent to any healthcare professional; it is written primarily for nurse managers.

KEY ISSUES: Error is inevitable. Causation is often attributed to individuals, yet causation in complex environments such as healthcare is predominantly multi-factorial. Individual performance is affected by the tendency to develop prepacked solutions and attention deficits, which can in turn be related to local conditions and systems or latent failures. Blame is often inappropriate. Defences should be constructed in the light of these considerations and to promote error wisdom and organizational resilience.

CONCLUSION AND IMPLICATIONS: Managing and learning from error is seen as a priority in the British National Health Service (NHS), this can be better achieved with an understanding of the roots, nature and consequences of error. Such an understanding can provide a helpful framework for a range of risk management activities.