<XML><RECORDS><RECORD><REFERENCE_TYPE>7</REFERENCE_TYPE><REFNUM>8825</REFNUM><AUTHORS><AUTHOR>Johnson,C.W.</AUTHOR></AUTHORS><YEAR>2006</YEAR><TITLE>Human Factors of Healthcare Reporting Systems</TITLE><PLACE_PUBLISHED>P. Carayon (ed), A Handbook of Human Factors and Ergonomics in Healthcare and Patient Safety, Lawrence Erlbaum, London, UK</PLACE_PUBLISHED><PUBLISHER>Lawrence Erlbaum Associates</PUBLISHER><PAGES>525-560</PAGES><ISBN>0-8058-4885-1</ISBN><LABEL>Johnson:2006:8825</LABEL><KEYWORDS><KEYWORD>Healthcare safety</KEYWORD></KEYWORDS<ABSTRACT>This chapter focuses on the problems of determining why a mishap occurs. In particular, the following pages consider a number of different perspectives on the role of human ‘error’ as a causal factor. Several authors have identified the ‘perfective’ approach to incident analysis in healthcare systems (Johnson, 2003, Helmreich and Merritt, 1998). In the past, many medical adverse events have been ‘blamed’ on the clinicians who were most closely involved in the immediate events leading to an adverse event. This led to recommendations that focussed on improvements in operator performance, most often this involved exortations to ‘be more careful’ or to attend additional training sessions. More recently, however, attention has shifted away from the individuals at the ‘sharp end’ of an adverse event. This work has contributed to the popularity of “systemic” theories as an explanation of accident causation (Leveson, 2003). In this view, individual errors rarely create the causes of an adverse event. Instead, we must look at the complex conjunction of managerial, regulatory and even legislative constraints that jeopardised the safety of a more general ‘system’. There are problems with this approach. It arguably undervalues the importance of individual responsibility. It also creates a recursive problem when we must try to understand the circumstances that led, for example</ABSTRACT><URL>http://www.dcs.gla.ac.uk/~johnson/papers/Pascale_book/incident_analysis.PDF</URL></RECORD></RECORDS></XML>