- the systems we design around the humans
and
-
the choices of humans within those systems
The resulting harm and the human errors (slips, lapses, and mistakes) that may have caused it are really two forms of outcome—outcomes to be monitored, studied, and perhaps grieved. Systems and choices are where the action is, with culture referring to the choices made within the system.
The first origin of adverse events is system design.
Systems develop over time. From simple surgical instruments to robotic surgery, from messages delivered via horseback to satellite phones, systems keep getting smarter and smarter. Collections of components, physical and human, keep getting more complex and tightly coupled, from getting steam locomotives to run on time, to organizing a mission to Mars. As system designs mature, we try to make the fit right for human beings within those systems. We do our best to design around the inescapable fallibility of human beings — that propensity to do other than what we intended. Better human factors design means less human error.
Choice is the second origin of adverse events.
Design safe systems and help employees make safe choices within those systems. Humans are not computers — we have free will (although this is sometimes challenged amongst experts in the safety field). We make choices that impact the rate of adverse events. That said, understanding human choice is a messy business, often set aside in favor of the more simplistic explanation of human error. Even graduate safety courses spend little time on managing choice — it’s all about human error. A commercial truck driver who crosses the centerline of a highway may very well be said to have made a human error. Yet, both design of the highway and truck may have contributed to the error, as would natural elements like rain or glare. So too would the choices of the driver contribute to his own error—from the decision to send a text message while driving to the decision to drink and drive."
Source: Safety Cultures, Safety Models, Taking Stock and Moving Forward, 2018, Claude Gilbert, Benoît Journé, Hervé Laroche, Corinne Bieder
