ABSTRACT
There are various approaches that have been adopted to identify the precursor and contributing factors of adverse clinical incidents involving patients in health care. While human factors classifications systems that have been developed for health care are diverse in their structure, what is common across the literature is that human factors, particularly human error, plays a leading role in clinical incidents. Errors, defined as ‘the failure of a planned action to proceed as planned’ (US Institute of Medicine 2000), have been retrospectively analyzed in health care, but studies differ in the way that medical errors are classified. Many analyses used job-related descriptions of the nature of errors. For example, in a study of errors in radiology, the error classification included ‘request for wrong patient’, ‘illegible request’ or ‘duplicate request’ (Martin 2005). This type of approach is informative in providing direction in which task or job areas where errors are most likely to occur, but it is not descriptive in terms of the type of cognitive failure that explains why the particular error type occurred. The obvious advantage of cognitive classifications of error is that they provide insight into the nature of error itself which is helpful in understanding why it occurred.
