This is not the blog I have always wanted to write; rather it is a blog I wish I had read early in my career. The central theme of the blog is error – that most vulnerable of human traits. Indeed failure is the nemesis that constantly shadows medical practice and tirelessly threatens to derail it.
I was drawn to the subject of human factors when I set out to understand how, as a newly-minted consultant neurologist, my thinking led me astray in the assessment of two patients whose faces remain indelibly engraved in my psyche. I realised with utter incredulity how doctors are trained to understand the human body, but not how their own minds work. I learnt that doctors are taught to be experts in the diagnosis and treatment of all sorts of diseases, but not in minding the factors that can derail these processes.
This blog will emphasise the truism in the saying, “to err is human“, and it will describe how this human frailty is nurtured by faulty mental shortcuts and systemic pitfalls. It will attempt to explore the diverse facets of this ubiquitous menace, digging up its roots and examining its branches. It will look at how the internal workings of our minds set us up to fail, and how error awareness helps to mitigate this. We will also examine how the systems and cultures in which we work lie at the heart of almost every human error, and how simple measures may go a long way to minimise their malign influence. The blog will also review how errors impact on victims and ‘perpetrators’ alike, and how the best error management systems need to take these opposing dimensions into consideration. Let us then prepare to start our initiation into human error.