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Human factors in error

29 October 2019

It has been said that “to err is human”.[1] Dr Annalene Weston, dentolegal adviser at Dental Protection, highlights the human factors that can contribute to error in dental practice – and considers how to address them

We cannot remove error from healthcare, as we cannot uncouple from our own humanity. We can, however, recognise precursors to error and address these to limit their impact on our patients.

Naturally, healthcare is not the only discipline focused on identifying and managing risk, with other high-risk industries also pursuing the paradigm of perfection. Aviation, in particular, has made great inroads into the identification of human error signs, identifying that there are more than 300 error incident precursors at play.[2] These have been distilled into the ‘dirty dozen’[3] – 12 key elements that are proven to influence people into making mistakes.

The dirty dozen is listed in no particular order, and at first blush it is easy to see how each of these could contribute to human error individually, and how in combination they could act to amplify the risk of that practitioner:

1. Lack of communication

Both between practitioner and patients, and practitioners and staff members.

2. Distraction

From our core role, which may be related to factors inside or outside our workplace, or simply due to tiredness.

3. Lack of resources

Particularly if accompanied by an unanticipated rise in demand.

4. Stress

In all its many manifestations, and with its far-reaching effects.

5. Complacency

Whether through over-familiarity, lack of respect for the process, or simple boredom.

6. Lack of teamwork

Perhaps as a direct result of steep practice hierarchies, disempowerment of certain staff members, clunky processes, or maybe even due to a disruptive member of the team.

7. Pressure

Both personal and workplace-related pressures can impact on our risk.

8. Lack of awareness

Of what we are trying to achieve or perhaps of how our behaviour and actions could be impacting on others.

9. Lack of knowledge

Perhaps we don’t know enough to do the job well, or we don’t have a full and thorough understanding of the regulations and processes we are required to follow to ensure patient safety.

10. Fatigue

Fatigue impacts on our cognition and behaviour and, consequently, it increases our risk. This has been borne out in road safety research that tells us “that being awake for 17 hours has the same effect on your driving ability as a BAC (blood alcohol concentration) of 0.05. Going without sleep for 24 hours has the same effect as a BAC of 0.1, double the legal limit”.[4]

When we consider the above research relating fatigue to blood alcohol concentrations, could we accept then that fatigue likely affects our dentistry?

11. Lack of assertiveness

If we cannot speak up for safety, both by setting safe boundaries for our practice, and raising concerns with a colleague about their intended practice, then we cannot truly ensure patient safety.

12. Norms

As in normalisation of sub-par performance or behaviours, often referred to within Dental Protection as ‘ethical fade’.

If we accept the above list as valid and applicable to healthcare we can use this knowledge to identify these precursors in our own practices by considering: has our teamwork stalled due to breakdowns in communication and the outstripping of resourcing by our demand? Are we stressed, tired and distracted?

But why would we care? Isn’t the ‘dirty dozen’ endemic through all businesses? And do they really do any harm?

Regretfully, human error is linked to harm, at alarmingly high levels. A recent meta-analysis undertaken to systematically qualify the prevalence, severity and nature of preventable patient harm confirms this, concluding that around one in 20 patients are exposed to preventable harm in medical care; going on to say that at least 12% of preventable patient harm causes permanent disability or patient death.[5]

Perhaps then, if we are to meaningfully manage our risk at work, our focus needs to be on eliminating the dirty dozen from our workplaces, bearing in mind that stress and fatigue are also linked to burnout. Perhaps too, to truly address the pervasive nature of stress, fatigue and burnout we need to start by approaching this subject without apportionment of fault or blame on the practitioners, but from a position of support. As “to err is human, to forgive divine”.[6]



[1] Alexander Pope

[5] Panagioti M et al, Prevalence, severity, and nature of preventable patient harm across medical care settings: systemic review and meta-analysis, BMJ 2019; 366:4185

[6] Alexander Pope