Combating omission errors through task analysis and good reminders
Combating omission errors through task analysis and good reminders
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通过任务分析和良好的提醒来消除遗漏错误
作者：
James T. Reason
遗漏必要的任务步骤是最常见的人为错误类型。某些任务步骤具有比其他步骤更容易引起遗漏的特征，并且可以提前识别。本文报告了两项研究。第一个涉及一台简单的复印机，确定未能删除原件的最后一页是最常见的遗漏。此步骤具有四个不同的引起错误的特征，这些特征以相加的方式将它们的效果联合收割机组合在一起。第二项研究考察了日常记忆辅助工具在多大程度上满足了好的提醒的五个特征：显著性、连续性、内容、上下文和可数性。一个密切的对应关系被发现之间的百分比使用的策略和他们满足这五个标准的程度。概述了一个三阶段的遗漏管理方案：一些安全关键活动的任务分析（识别离散的任务步骤）;评估每个步骤的遗漏可能性;以及选择和应用合适的提醒。这种方案适用于各种保健程序。
Leaving out necessary task steps is the single most common human error type. Certain task steps possess characteristics that are more likely to provoke omissions than others, and can be identified in advance. The paper reports two studies. The first, involving a simple photocopier, established that failing to remove the last page of the original is the commonest omission. This step possesses four distinct error-provoking features that combine their effects in an additive fashion. The second study examined the degree to which everyday memory aids satisfy five features of a good reminder: conspicuity, contiguity, content, context, and countability. A close correspondence was found between the percentage use of strategies and the degree to which they satisfied these five criteria. A three stage omission management programme was outlined: task analysis (identifying discrete task steps) of some safety critical activity; assessing the omission likelihood of each step; and the choice and application of a suitable reminder. Such a programme is applicable to a variety of healthcare procedures.