ABSTRACT
Human components were considered as additional elements in the system, similar to other technical components. Just as technical safety is improved through the reduction of technical breakdowns, it seemed common sense to use a symmetrical rationale to improve safety through the reduction of human errors. The methods used represent an extension of the information-processing, cognitive science tradition. While many errors occurred, most of them were often detected and resolved very quickly, either through communication between team members or feedback from the ICU environment. For instance, continued use of a sedative to deal with patient pain was quickly rejected as a treatment plan when one team member realized that it was contributing to liver failure. Where human activity is seen as dynamic adaptation to the work environment, most errors can be considered as the price paid for making compromises in trading off between various alternatives.
