‘Mistaking error’ – an earlier paper from David Woods & Richard Cook

A banger from Woods and Cook exploring the notions of ‘error’. Originally from 2004 and updated in 2012.

I’ve skipped heaps – so check out the full paper.

They argue that:

·        They refer to the progressive, adaptive perspective as the ‘New Look’

·        Error is used inconsistently, since it can mean:

o  1) a cause of failure, e.g. “the accident was due to human error”,

o  2) error as the failure itself, e.g. “the mix-up was due to an error”,

o  3) error as a process, e.g. a departure from a ‘good’ process

·        People may confuse different meanings of error without being aware of doing so

·        They argue that the ‘New Look’ has produced four conclusions relating to ‘error’

·        Conclusion 1) defining error as a cause blocks learning by hiding the lawful factors that affect human and system performance. Moreover, errors aren’t heterogeneous and not directly comparable events for counting and tabulating, and they may trivialise expert human performance

·        Conclusion 2) defining error as consequences is redundant and confusing. They argue that conflating error with harm incorporates a fuzzy model of how accidents happen, and gives the appearance of progress where there’s none. Instead, just stick with clear language

·        Conclusion 3) Defining error as deviation from a model of ‘good’ process collides with the problem of multiple standards. How do we identify the standard, in what granularity, dictate how many ‘errors’ you find. There is also a ‘slipperiness’ in what counts as a deviation

·        Conclusion 4) labelling an act as ‘error’ marks the end of the social and psychological process of causal attribution

·        How people apply the term ‘error’ is more about their reaction to failure and hence, the use of error “is less revealing about the performance of workers than it is about ourselves as evaluators”

·        Error isn’t a fixed category of scientific analysis, nor an objective, stable state of the world

·        In the final image, they discuss different perspectives of people: one of an erratic role in degrading otherwise safe systems, and the other is how people create safety under resource and performance pressure.

·        In the latter, people are simultaneously “the source of success and failure”

Ref: Woods, D. D., & Cook, R. I. (2003). Mistaking error. Patient safety handbook, 95, 108.

Study link: https://www.researchgate.net/profile/David-Woods-19/publication/328149714_Mistaking_Error/links/5bbbaf8392851c7fde341bb5/Mistaking-Error.pdfmy

My site with more reviews: https://safety177496371.wordpress.com

LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_a-banger-from-david-woods-and-the-late-richard-activity-7198434751081242624-XuWe?utm_source=share&utm_medium=member_desktop