Abstract
Human error is as old as humanity itself and occurs on a daily basis, whatever we
are doing. Recognising our fallibility is the first step to understanding error and
ways to reduce it. The term “never event” is, therefore, a misnomer as these serious
adverse incidents can never be eliminated completely. Up to 1 in 20 hospital admissions
includes some form of error, and while many have little detrimental effect on patients’
care (such as forgetting to write a discharge summary), 6% are serious. Many medical
errors could have been prevented through the understanding and application of human
factors (HF) including (but not exclusively) better team working, situational awareness,
and the lowering of authority gradients. In this article we provide an overview of
error and introduce the concept of threat and error management (TEM) which is used
in other, high-reliability organisations, and provides three layers of defence to
reduce the effect or severity of any error. We discuss how to try and avoid medical
error in the first place (the first line of defence), trap errors when they occur,
and mitigate the consequences of any error to help further safeguard our patients.
Keywords
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Article info
Publication history
Published online: January 23, 2020
Identification
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© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
