Getting to the root of the problem - human error or system failure?

Clinicans need to identify systems threatening patient safety

When patient safety is compromised, clinicians and managers need to examine their systems to see why dedicated, skilled staff make mistakes, says Rita Devlin

Every day in emergency departments (EDs) across the UK, patients receive high-quality care from skilled clinicians. It is delivered despite growing workloads and increasingly complex patient conditions.

Behaviour cogs
Understanding wokforce behaviour performances to identify mistakes
Picture: Alamy

However, an unacceptable number of patients are harmed inadvertently due to actions or omissions by clinicians, or as a consequence of their admission to hospital. The challenge for managers and clinicians is not to understand why bad people produce adverse events, but to understand why good people do.

Enhancing performance

The science of human factors is the understanding of human performance in a given system. In healthcare, it has been defined as ‘enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities and application of that knowledge in clinical settings’ (Dekker 2011).

Like all humans, healthcare professionals will make errors, irrespective of how experienced, committed, competent and careful they are.

Dekker (2011) describes two views of human error. The first sees it as a medical competence problem, perceiving healthcare as basically safe and needing protection from unreliable humans. The second views human error as an organisational problem. Here healthcare is not perceived as inherently safe.


Imagine an ED with eight-hour waiting times has 12 patients waiting for admission. A patient who needs medication for Parkinson’s disease is lying on a trolley in a corridor. A relative alerts the nurse he needs his medication. The nurse discovers the medication is not stocked in the ED and requests it from the pharmacy.

By the time it is delivered, she is busy with other patients and the man becomes agitated. He tries to get out of bed, but falls and fractures his hip.


Those who view human error as a medical competence problem will think the nurse in the scenario is at fault. At best, they may counsel and support the nurse. At worst, her competence will be questioned. She might even be referred to the Nursing and Midwifery Council. The context that led to the mistake will not be addressed and the mistake may occur again.

But those who view human error as an organisational problem will look systematically at why the problem occurred. It will be a starting point for a deeper investigation of EDs, and they will look to fix the broken system rather than the broken nurse.

According to the World Health Organization (WHO) (2005), 'what every clinician and manager needs to understand is the system is not basically safe…every point in the process of care giving contains a certain inherent lack of safety’. Only when we accept this can we start implementing ways of working to improve safety.

Workload rise

The healthcare system is full of contradictions as people pursue multiple goals simultaneously. Clinicians charged with meeting targets, for example, are also charged with not making mistakes. They are asked to work quicker and more efficiently, but the workload keeps rising and the workforce decreases. Clinicians are asked to do more with less and without making errors.

Staff suffering from burnout and fatigue are the people we rely on most to keep alert and establish safety.

It is therefore important for clinicians to identify those systems threatening patient safety and to develop safer ones to manage the increasing complexity of the health service.


 About the author

Rita Devlin

Rita Devlin is head of professional development at the Royal College of Nursing, Northern Ireland

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