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Application of Human Error Theory in Case Analysis of Wrong Procedures

Duthie, Elizabeth A. RN, PhD

doi: 10.1097/PTS.0b013e3181de47f9
Original Articles

Objectives: The goal of this study was to contribute to the emerging body of literature about the role of human behaviors and cognitive processes in the commission of wrong procedures.

Methods: Case analysis of 5 wrong procedures in operative and nonoperative settings using James Reason's human error theory was performed.

Results: The case analysis showed that cognitive underspecification, cognitive flips, automode processing, and skill-based errors were contributory to wrong procedures. Wrong-site procedures accounted for the preponderance of the cases. Front-line supervisory staff used corrective actions that focused on the performance of the individual without taking into account cognitive factors.

Conclusions: System fixes using human cognition concepts have a greater chance of achieving sustainable safety outcomes than those that are based on the traditional approach of counseling, education, and disciplinary action for staff.

From the New York University College of Nursing, New York, New York.

Correspondence: Elizabeth A. Duthie, RN, PhD, New York University College of Nursing, 726 Broadway, 10th Floor, New York, NY 10003 (e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.