An analysis of work activity in the operating room: Applying psychological theory to lower the likelihood of human error

摘要

We report on our observations in the operating room, where we examined the work activity in hopes of understanding why human errors can occur even with simple tasks (e.g., loading a syringe with the wrong solution). We employed a human factors analysis guided by our understanding of human cognition (memory, attention, action planning, etc.) with the goal of improving safety. By applying psychological theory (human cognition) to this real-world environment, we suggest where human error is prone to occur due to factors such as non-optimal procedures and design layout. We speculate that such weaknesses can contribute to adverse events and offer low-cost solutions aimed at minimizing the likelihood of such errors occurring.