Capturing psychological mechanisms in error reports

Ergonomics journal April 2006

'From cognition to the system: developing a multilevel taxonomy of patient safety in general practice.' O Kostopoulou

In developing a taxonomy the author has raised a few interesting issues.

If a GP does not prescribe necessary medication for a patient it could be seen as his/her error or failure. But it may be that he could not read the handwritten request from the hospital so there is an external cause and performance shaping factors, but no psychological mechanism or immediate internal causes.

Suggested that it would be better to replace the terms 'error' and 'failure' with the term 'action' as this would be more constructive and blame free.

Other taxonomies, such as those based on the slips, lapses, mistakes framework can only be used to classify errors.

Fear of blame, particularly in the medical industry can severely reduce the likelihood of talking about and learning from patient safety events. Certainly where terms such as 'carelessness' or 'thoughtlessness' are included in a taxonomy. This can also be the case where classifications are allocated either to systems or humans, which can reinforce the blame culture by concentrating attention on the error producing human as distinct from the error inducing system.

Performance shaping factors are likely to change as policies, systems and technologies change. For example introducing an electronic prescription system will eliminate handwriting issues but introduce new opportunities for error, such as selecting the wrong item from an alphabetical list of medicines.

The study highlights the importance of identifying the psychological mechanism that led to an error. This requires an understanding of the cognitive basis of behaviour. In many cases reporting systems do not capture that sort of information and it will not be obtained unless incidents are followed up very quickly. The idea of the taxonomy is to capture that information.

Andy Brazier