ABSTRACT
This chapter addresses human contributing factors and how they interact with failures in the system to breach its defences. It fascinates the extraordinary capacity of human beings to continuously intercept things that are going wrong and steer the trajectories of evolving events away from potential tragedy towards safe and successful outcomes. The chapter argues that accidents are inevitable in complex systems. Healthcare is a complex system comprising humans, infrastructure, technology and therapeutic agents; these components interact in highly complex, almost infinitely variable ways. The chapter discusses the often contentious relationships between error, outcome, blame and culpability. There are many classifications of error: Errors in information, Errors in acquisition of knowledge, Errors in perception, Errors in matching, Errors in knowledge stored as schemata, Errors in knowledge stored as rules, Skill-based errors – slips and lapses, Errors in choice of rule, Technical errors and Deliberative errors.
