Wednesday, 10 February 2016

Book of the month: A life in error: from little slips to big disasters by James Reason

About the author

James Reason is one of the greats in human factors research. English Wikipedia does not have an entry for him (the French site does). Instead we have to content ourselves with a page on perhaps his major contribution to broadening the appeal and understanding of human factors, the Swiss cheese model of accident causation. Reason is Professor Emeritus of Psychology at the University of Manchester and has authored numerous papers and books on human factors, including: Human error, The Human Contribution and Managing Maintenance Error (A Practical Guide)

Who should read this book?

Anybody with an interest in human factors and patient safety (see below for why).

In summary

The book consists of 14 chapters:
  1. A Bizarre Beginning
  2. Plans, Actions and Consequences
  3. Three Performance Levels
  4. Absent-minded slips and lapses
  5. Individual differences
  6. A Courtroom Application of the SIML (Short Inventory of Mental Lapses)
  7. The Freudian Slip Revisited
  8. Planning Failures
  9. Violations
  10. Organizational accidents
  11. Organizational Culture: Resisting Change 
  12. Medical Error
  13. Disclosing Error
  14. Reviewing the Journey

What’s good about this book?

The book is very well written and easy to read. Reason takes us on an humorous, insightful, autobiographical journey from his first encounter with "human error" to his later theories. The book explains a number of concepts. For example, Reason argues that some familiar objects develop local control zones (p.3). In healthcare, an IV cannula may exhibit this property. If one finds oneself with a syringe in hand, distracted and near a cannula there is a strong possibility that one will inject the contents of the syringe into the cannula. When the syringe contains local anaesthetic or 1:1000 adrenaline this may result in adverse consequences.

Reason talks about differences between novices and experts. The former show a lack of competence, while the latter are much more likely to commit absent-minded slips, i.e. misapplied competence (p.21). Reason argues that, in absent-mindedness, it is the suppressive function which goes absent. Pre-programmed, habitual actions are normally actively suppressed, but in "strong habit intrusions" they are carried out by the distracted person.

Reason discusses the "Stress-vulnerability hypothesis", people under chronic stress are more likely to have cognitive failures such as absent-minded slips and lapses (p.33). However he argues that association is not causation, and it may be that people who are more likely to complain of chronic stress may also me more likely to be absent-minded, i.e. that the same poor cognitive resource management is responsible for both.

In his discussion of planning/decision-making, Reason describes the planning process and the sources of bias which lead to failure, grouping them by planning stage (p.56):
  1. Working database (e.g. recency, successes better recalled than failures)
  2. Mental operations (e.g. covariation, "halo", hindsight)
  3. Knowledge schema (e.g. confirmation, resistance to change, "effort after meaning")

For those interested in groups and organisations, Reason discusses "satisficing", i.e. groups will tend to select the first satisfactory outcome rather than an optimal one. He also looks at the heuristics of group decision-making, such as avoidance of uncertainty and selective organisational learning (p.59).  In terms of accidents, Reason contrasts "individual" (frequent, limited) and "organisational" (rare, devastating) accidents. He therefore agrees with Steven Shorrock that having a sign which says e.g. "135 days since our last accident" does not tell you how safe the system is. Why? Because they have different causal sets (p.79).

"Turning a blind eye" (Nelson commits a violation, p.68)
In terms of violations, that is conscious decisions to ignore or circumvent a rule, Reason argues that it is better to focus on decreasing the benefits of violations rather than trying to increase the costs of doing so. This means that one should look at why the system is promoting violations rather than punishing individuals for committing them.

Reason also covers latent conditions, active failures and how they combine with local triggers into an accident trajectory (p.75).

What’s bad about this book?

At 124 pages, this is a short book, however it is probably too short. A lack of explanation may leave some readers puzzled. For example, on p.30 Reason states: "The correlation between [two independent samples of the Short Inventory of Mental Lapses] over the 15 items was 0.879." It would probably have been better to leave out the numbers or to explain them. His coverage of the planning process and its biases is too short and superficial, he mentions "groupthink" (p.61) and provides 8 main symptoms but does not explain these in sufficient detail to allow one to use this knowledge in practice.

Final thoughts

This book spans the whole gamut of human factors science and touches on a great number of subjects including all the above, as well as a typology of safety cultures, vulnerable system syndrome (blame, deny, pursue wrong goals), why and how organisations resist change, models of medical error (plague, legal, person, system) and more. And if you would like an easy-to-read, broad introduction to human factors and healthcare then this book is a must-read.