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Still Not SafePatient Safety and the Middle-Managing of American Medicine$
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Robert Wears and Kathleen Sutcliffe

Print publication date: 2019

Print ISBN-13: 9780190271268

Published to Oxford Scholarship Online: November 2019

DOI: 10.1093/oso/9780190271268.001.0001

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Three Views of “Human Error”

Three Views of “Human Error”

Chapter:
(p.57) 5 Three Views of “Human Error”
Source:
Still Not Safe
Author(s):

Robert L. Wears

Kathleen M. Sutcliffe

Publisher:
Oxford University Press
DOI:10.1093/oso/9780190271268.003.0005

The concept of human “error” was central to patient safety’s rise to prominence. Unfortunately healthcare developed a rather limited understanding of “error” from a complex body of work that had been evolving from different disciplines, such as psychology, sociology, and organization science. A focus on “human error” and this deficit thinking proved useful to healthcare as it was undergoing a managerial turn. The so-called “Clambake Conferences” exemplified a broad range of evolving thought about accidents and error, and the utility of the very concept of “error” became challenged.

Keywords:   Three Mile Island, Tenerife, heuristics, biases, deficit model, hindsight bias, Amos Tversky, Daniel Kahneman, Charles Bosk, Marianne Paget, Marcia Millman, Donald Norman, James Reason, Charles Perrow, Gene Rochlin, high reliability, normal accidents, Swiss cheese model, Jens Rasmussen, Diane Vaughan

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