Human Performance

Questions about patient safety, fundamentally, are questions about human performance. How do we influence, for example, expertise, control of attention, teamwork, human-computer cooperation, and organizational learning? The target is to understand how practitioners accomplish their goals in the face of a variety of difficulties, complexities, dilemmas and tradeoffs and how this usually successful process breaks down. Inquiry on these topics is focused on understanding what factors create complexity and how people in different roles coordinate to cope with complexity.

The methods used in this work come from Cognitive Science and Engineering (protocol analysis, cognitive work analysis), Anthropology (ethnography), and other fields outside of medicine. Health care does not normally use these methods to examine human performance, cooperative activity and organizational dynamics. Furthermore, the very character of these methods is quite different from methods typically deployed by engineers. Building the Story, charting the process of how the problem is recognized and solved -- is a core and illuminating activity that precedes statistical aggregation of the resulting patterns.

Ultimately, this is an issue about how to combine two families of knowledge; one family concerns different areas of knowledge and experience in a specific field of practice and the other family concerns different areas of knowledge about human performance. Success will come from interdisciplinary efforts using methods to understand and enhance human expertise in the context of diverse and changing settings.

Taken from  The New Look at Error, Safety, and Failure: A Primer (pdf)
Authors: David Woods, Ph.D. & Richard I. Cook, M.D.

If you cannot view the PDF, you can download the necessary Adobe Acrobat Reader.

BACK to the Patient Safety Concepts page