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Human Error James Reason Epub !!BETTER!! Download



Leape8 greatly enhanced our understanding of errors by distinguishing between two types of cognitive tasks that may result in errors in medicine. The first type of task occurs when people engage in well-known, oft-repeated processes, such as driving to work or making a pot of coffee. Errors may occur while performing these tasks because of interruptions, fatigue, time pressure, anger, distraction, anxiety, fear, or boredom. By contrast, tasks that require problem solving are done more slowly and sequentially, are perceived as more difficult, and require conscious attention. Examples include making a differential diagnosis and readying several types of surgical equipment made by different manufacturers. Errors here are due to misinterpretation of the problem that must be solved and lack of knowledge. Keeping in mind these two different kinds of tasks is helpful to understanding the multiple reasons for errors and is the first step in preventing them.




human error james reason epub download



People make errors for a variety of reasons that have little to do with lack of good intention or knowledge. Humans have many intellectual strengths (e.g., large memory capacity and an ability to react creatively and effectively to the unexpected) and limitations (e.g., difficulty attending carefully to several things at once and generally poor computational ability, especially when tired).12 Improving safety requires respecting human abilities by designing processes that recognize human strengths and weaknesses.


Individuals cannot remain vigilant for long periods of time. Approaches for reducing the need for vigilance include providing checklists and requiring their use at regular intervals, limiting long shifts, rotating staff, and employing equipment that automates some functions. The need for vigilance can be reduced by using signals such as visual and auditory alarms. Also, well-designed equipment provides information about the reason for an alarm. There are pitfalls in relying on automation, if a user learns to ignore alarms that are often wrong, becomes inattentive or inexpert in a given process, or if the effects of errors remain invisible until it is too late to correct them.


Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDS--three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems.


To Err Is Human breaks the silence that has surrounded medical errors and their consequence--but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agenda--with state and local implications--for reducing medical errors and improving patient safety through the design of a safer health system.


This chapter discusses actual social disasters and damages they caused. The first section starts with some societal problems we face today. They are accidents due to aging infrastructures and difficulties in preventing them, nature and trends in accidents involving airplanes which are one of the most advanced industrial products today, characteristics of automobile accidents with the most serious social disasters in modern society in terms of the number of deaths and injured, and drug toxicity and safety in medical care. The following Sect. 7.2 analyzes human error, which is the most important factor in conducting analysis and investigation of accidents. Lastly, the third section closes the chapter with an overview of the history of major social disasters and their countermeasures.


The advancement of scientific technology is also pointing at development and improvement of methodologies for human problem-solving and education and training for enhancing problem-solving skills. The human nature, however, has not made much of a difference since the birth of humankind. Therefore, when the difficulty with performance requirement is over the limitations of human, or when the abilities of the performer are insufficient or inadequate, the odds for incidents or accidents to take place go up. The concept of human error comes with inadequate action by human from inabilities or inadequate responses that leave the given task incomplete.


Next, it was human error that caught the attention. Technical measures advanced and mechanical failures turned rare; however, with the magnitude of energy that humans control, minor mistakes caused huge disasters. The managing side had the idea that if they emphasized human error, they could avoid the cost of improving facilities and the work environment. Later studies of human factor, however, clarified that taking an error as the result, rather than the cause, and working countermeasures would better improve the safety. This finding led to implementing a countermeasure for each factor that could lead to an error, as we discussed in the former section.


In this study, we aimed to establish the normal range, potential sources of error and confounds of native myocardial T1 relaxation times in a large cohort of healthy human volunteers. T1-mapping was performed at 1.5T using the Shortened Modified Look-Locker Inversion Recovery (ShMOLLI) technique [12]. We examined the effects of normal physiologic parameters, including age, gender, heart rate, weight, height and hematocrit, as well as technical factors, such as partial volume effects, myocardial thickness and inter-centre variability on identical scanners within and across three clinical centres in two countries.


Although times change and knowledge increases, it is possible to discern a core of philosophical insight within the history of thought as a whole. Consider, for example, the principles of non-contradiction, finality and causality, as well as the concept of the person as a free and intelligent subject, with the capacity to know God, truth and goodness. Consider as well certain fundamental moral norms which are shared by all. These are among the indications that, beyond different schools of thought, there exists a body of knowledge which may be judged a kind of spiritual heritage of humanity. It is as if we had come upon an implicit philosophy, as a result of which all feel that they possess these principles, albeit in a general and unreflective way. Precisely because it is shared in some measure by all, this knowledge should serve as a kind of reference-point for the different philosophical schools. Once reason successfully intuits and formulates the first universal principles of being and correctly draws from them conclusions which are coherent both logically and ethically, then it may be called right reason or, as the ancients called it, orthós logos, recta ratio.


5. On her part, the Church cannot but set great value upon reason's drive to attain goals which render people's lives ever more worthy. She sees in philosophy the way to come to know fundamental truths about human life. At the same time, the Church considers philosophy an indispensable help for a deeper understanding of faith and for communicating the truth of the Gospel to those who do not yet know it.


8. Restating almost to the letter the teaching of the First Vatican Council's Constitution Dei Filius, and taking into account the principles set out by the Council of Trent, the Second Vatican Council's Constitution Dei Verbum pursued the age-old journey of understanding faith, reflecting on Revelation in the light of the teaching of Scripture and of the entire Patristic tradition. At the First Vatican Council, the Fathers had stressed the supernatural character of God's Revelation. On the basis of mistaken and very widespread assertions, the rationalist critique of the time attacked faith and denied the possibility of any knowledge which was not the fruit of reason's natural capacities. This obliged the Council to reaffirm emphatically that there exists a knowledge which is peculiar to faith, surpassing the knowledge proper to human reason, which nevertheless by its nature can discover the Creator. This knowledge expresses a truth based upon the very fact of God who reveals himself, a truth which is most certain, since God neither deceives nor wishes to deceive.6


14. From the teaching of the two Vatican Councils there also emerges a genuinely novel consideration for philosophical learning. Revelation has set within history a point of reference which cannot be ignored if the mystery of human life is to be known. Yet this knowledge refers back constantly to the mystery of God which the human mind cannot exhaust but can only receive and embrace in faith. Between these two poles, reason has its own specific field in which it can enquire and understand, restricted only by its finiteness before the infinite mystery of God.


28. The search for truth, of course, is not always so transparent nor does it always produce such results. The natural limitation of reason and the inconstancy of the heart often obscure and distort a person's search. Truth can also drown in a welter of other concerns. People can even run from the truth as soon as they glimpse it because they are afraid of its demands. Yet, for all that they may evade it, the truth still influences life. Life in fact can never be grounded upon doubt, uncertainty or deceit; such an existence would be threatened constantly by fear and anxiety. One may define the human being, therefore, as the one who seeks the truth.


The same must be equally true of the search for truth when it comes to the ultimate questions. The thirst for truth is so rooted in the human heart that to be obliged to ignore it would cast our existence into jeopardy. Everyday life shows well enough how each one of us is preoccupied by the pressure of a few fundamental questions and how in the soul of each of us there is at least an outline of the answers. One reason why the truth of these answers convinces is that they are no different in substance from the answers to which many others have come. To be sure, not every truth to which we come has the same value. But the sum of the results achieved confirms that in principle the human being can arrive at the truth.


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