Biomedical subjects
Publications and source records attributed to J T Reason.
In this review, we discuss human factors research in cardiac surgery and other medical domains. We describe a systems approach to understanding human factors in cardiac surgery and summarize the lessons that have been learned about critical incident and near-miss reporting in other high technology industries that are pertinent to this field.
Investigations of accidents in a number of hazardous domains suggest that a cluster of organisational pathologies-the "vulnerable system syndrome" (VSS)-render some systems more liable to adverse events. This syndrome has three interacting and self-perpetuating elements: blaming front line individuals, denying the existence of systemic error provoking weaknesses, and the blinkered pursuit of productive and financial indicators. VSS is present to some degree in all organisations, and the ability to recognise its symptoms is an essential skill in the progress towards improved patient safety. Two kinds of organisational learning are discussed: "single loop" learning that fuels and sustains VSS and "double loop" learning that is necessary to start breaking free from it.
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OBJECTIVE: To study the role of human factors on surgical outcomes, with a series of 243 arterial switch operations performed by 21 surgeons taken as a model. METHODS: The following data were collected: patient-specific and procedural variables, self-assessment questionnaires, and a written report from a human factors researcher who observed the operation. The relationship of patient-specific variables to outcomes (death and death and/or near miss) was used to develop a multivariable baseline model to analyze the role of human factors after adjustment for these variables. RESULTS: The overall mortality was 6.6% with 24.3% of cases resulting in death and death and/or near misses. The self-assessment questionnaires were found to be unhelpful. Major and minor human failures were extracted from the written report. Major negative events were potentially life-threatening failures, whereas minor events were failures that, in isolation, were not expected to have serious consequences. Major events were closely related to death (P <.001) and death and/or near misses (P <.001). Appropriate compensation, however, sharply reduced the risk of death (P =.003). The total number of minor events was also closely related to both death and death and/or near misses (P <.001). CONCLUSION: The study highlights the role of human factors in negative surgical outcomes. Even in the most eventful circumstances, however, appropriate human factors defense mechanisms can lead to a successful outcome.
Ajzen's theory of planned behaviour was used to measure the attitudes and intentions of a large stratified sample of drivers (N = 881) towards four driving violations. Measures were taken of respondents' attitudes to four imaginary scenarios depicting their commission of the four violations concerned. Demographic subgroups of drivers within the sample were differentiated on the basis of their beliefs about and evaluations of their commission of the violations. We were able to identify attitude items differentiating the younger, statistically more "accident liable" drivers in the sample from their older, and statistically safer counterparts. The implications of using this approach to inform future road safety campaigns are discussed.
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The rates at which protective adaptation was acquired to an incremental cross-coupled stimulus were compared under three conditions of movement control: 1) a passive condition in which the 45 degree lateral tilts of the subject's chair were controlled entirely by the experimenter (N = 12); 2) an active condition in which the same movements were achieved directly through the subject's own muscular effort (N = 12); and 3) an active-passive condition in which control was exercised indirectly through microswitches located on the chair arms (N = 12). Adaptation was measured by the rate of neutralization of the oculogyral illusion, as estimated from the apparent motion of a small, dimly illuminated target. The results supported the prediction that the passive condition would be the least effective mode for acquiring adaptation. An unexpected finding was that the active-passive condition proved to be the most efficient for the development of adaptation.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.