Ergonomics journal April 2006
'Error detection: a study in anesthesia' A Nyssen and A Blavier
Accident reporting system developed and used to collect information about error detection patterns. A significant relationship was found between the type of error and and error detection mode, and between the type of error and the level of training of the anesthetist who committed the error.
It is not possible to prevent every error, so reducing their consequences is important, which requires detection. This has not been studied much, and the most of the studies have been on simple tasks in laboratory settings.
Six modes of detection were identified
1. Standard check (routine monitoring of the environment)
2. Recognising outcome signs
3. Suspicion from knowledge
4. Interpolation (by someone else, not person who committed error)
5. Alarm sounds
6. By chance
Standard checks were found to be most prominent. This suggests checking has become part of the routine activity and because it is non-specific it enables to staff to pick up many different types of error. It was found that the risk associated with the operation made little difference to the detection strategies employed.
More experienced staff become better at detecting a wider range of error types. It is suggested this is because they have more control over what they are doing and so can do more diverse things. This is like an experience musician being able to improvise more.
The authors suggest the findings from this study could have significant implications for safety. At present when errors occur in complex systems the tendency is to increase policies and procedures, which restrict actions and reduce opportunities to action options. This does not reduce the complexity of the system, but may reduce the opportunities people have to detect errors. Therefore, it may be better to concentrate on improving experience in order to increase the likelihood of error detection, rather than restricting activities with more procedures.
, followed by recognising signs and alarm.