Humans: the imperfect design
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Humans have both physical and cognitive limitations that can impact performance. However, humans also have strengths like the ability to learn from errors and successes. The document discusses three parts: limitations of the human design, managing those limitations, and learning from success rather than just failures. It argues for understanding both the downsides and upsides of human cognition and performance.
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Humans: the imperfect design
- 1. Humans the imperfect design A/Prof Stuart Marshall @hypoxicchicken Slideshare.net/StuartMarshall15
- 2. Part I - Limitations
- 10. Cultural and ‘tribal’ expectations
- 11. Part II – Managing Limitations
- 17. Complexity How do we understand it? How do we deal with it?
- 18. Klein – Sources of Power 1998 Part III Learning from success
- 22. “Trying to understand safety by only looking at incidents is like trying to understand sharks by only looking at shark attacks” Professor Bob Wears ED physician and HF researcher
- 25. Humans and the imperfect design Limitations but also strengths Learn for errors Learn from success
- 26. References and picture credits • Slide 1, 4, 25, 26 unattributed photo • Slide 2 unattributed photo • Slide 3 Apollo 11 Lunar module from Command module NASA • Slide 5 NHTSA www.drowsydriving.org Dawson and Reid, Nature 1997 388;235 • Slide 6 Photo: Johannes Plenio on Unsplash • Slide 7 ‘Tinman syndrome’ Radiopaedia.org • Slide 8 Photo: MUARC Monash University • Slide 9 Mopic on ClipArtOf Elizabeth Loftus “How reliable is your memory?” TED.com • Slide 10 Ott et al. Proceedings of HFES annual meeting 2007 • Slide 11 “Children in yard” on Publicdomainpictures.net • Slide 12 Photo by Oscar Keys on Unsplash • Slide 13 unattributed photo • Slide 15 N.Chrimes on #EZDrugID • Slide 16 Seagull et al. Proceedings of HFES Annual meeting 2007 • Slide 17 s1lentway on Reddit.com • Slide 18 Tan’am Oman Photo by NASA on Unsplash • Slide 19 Photo Andy Watkins Unsplash • Slide 21 Photo anonymous via Daniel Jolley with permission • Slide 22 Photo S. Shorrock, Humanistic systems • Slide 23 Unattributed image • Slide 24 Field with landmine warning Golan Heights (cropped) Adam Jones 2011 Flikr.com Staszewski, J.I. Proceedings of HFES 2004; 458-62
Editor's Notes
- My aim is to challenge and perhaps overturn the way you think about human error and human factors 3 Parts explaining our approaches to error and adverse events in health Take you from understanding that error is a normal human state to a new way of thinking about harm reduction in health On the way we’ll talk about minefields, space travel, firefighting, driving and even hypnosis
- You will need a pen and paper and to become friends with the person next to you While you’re preparing that I’ll just mention that the slides from this presentation will be available There’ll also be a recording of it Challenge is to draw a house on the paper but… Before you start there are two rules... 1) Both of you in pairs must hold onto the pencil – proper holding on, not just touching with one hand while the other draws 2) Neither of you are allowed to speak. The whole room should be silent (except perhaps for some raucous laughter…!) You have 3 minutes to draw OK. Now you’ll notice I’ve not been looking at your drawings. You are allowed to talk now. Rectangular, two or four windows in each corner, may have a cross into 4 panes maybe even curtains tied in the middle triangular roof, chimney possibly with smoke coming out of it Sun – in top right corner Tree on the right side of the picture... Path Who has ever seen a house like this? Why do we draw house like this then? Hold onto that thought
- Overview – limitations and imperfections What that means for us How are humans limited? Physically and cognitively
- Tale of procrustus Anaesthetic registrar’s hands
- Humans are limited by fatigue Know that accidents are 2-3 times higher after night shift Stanford story
- Going to show you how our actions are guided and limited by our hardware and software. Already seen that we are culturally wired to respond in specific ways Photo by Johannes Plenio on Unsplash
- Vigilance and attention is affected by what we expect to see.
- Vigilance Memory is flawed (Elizabeth Loftus) Not a recorder – more like a wikipedia page – you can change it and so can others! False memories are more common than we think. Unable to distinguish between them and true memories Primacy, recency, distinctiveness, frequency, associations
- Action selection Culturally influenced Priming – old versus young patient Slower, made more mistakes (Ott 2007)
- Summarise First part noted how we are wired in a way that might produce
- Photo by Oscar Keys on Unsplash Humans are flawed and limited that’s depressing ON the positive side we’re predictably flawed We can learn from errors and we do – error reporting, education How do we deal with that? Redesign systems to accont for common errors Already seen that we are culturally wired to respond in specific ways Learn from mistakes – regulate, eliminate risk
- We set up situations and designs as potentially dangerous First thing we do is to put signs on things and hope that it will detract people from doing it again Remove these. Create
- Start looking at basic design and removing potential sources of error Campaign to change connectors Look at vaporiser interlocks Hardware / Software / LIveware
- Then we try to develop procedures to prevent these These mostly work but are plagued by the idea that “Man is best when doing least” (Birmingham and Taylor 1954) Ambiguity, ignored, worked around *** MORE DETAIL Procedural drift – tend to become more complex and inflexible. Practical drift – not followed bc of confusion. Excessive consistency, Mgmt decisions Nuclear power assessment (Lintern 2012)
- Removing the human from the system story? Artificial Intelligence Dog pilot and computer Human factor as the weak point in the design – eliminate the human. Appropriate to remove humans from reaction tasks, vigilance tasks BLAME
- RCA versus the real world Boil things down to Tan’am Oman Photo by NASA on Unsplash Is it complex enough for us to deal with that? Recommendations from RCA are usually weak (reference!)
- Story – a complex situation (firefighting) Photo Andy Watkins Unsplash (Barry Island fire festival, UK)
- Routine situation - ingenuity
- Armband allergy
- What does that tell us - adaptability, problem solving People make safety by adapting situations in routine and emergency situations Humans are the strength in the system not a weakness to be eliminated People make safety by adapting situations in routine and emergency situations
- So this is how thinking about sharks can improve out understanding of PS This quote by Bob Wears from Florida What we fail to appreciate in managing the deteriorating patient is the role of the clinicians on the floor looking after the patient What they do on a regular basis to maintain the safety Rather than punishing when they occasionally get it wrong – find out why they get it right 99.9% of the time
- Land mine story CTA Antipersonnel low-metal mines 20% detection Identified Cognitive strategies of two exp individuals with higher success rates used different cog strategies to conventional (spatial patterns rather than auditory outputs) Trained over 20 hours standard detection rate increased to 95% Addition of new equipment that built on these cognitive processes improved detection rates to 97-100%
- Tried to do is to explain what the science of human factors is in a roundabout sort of a way Procrustean approach of cutting or stretching humans to meet the tools HF is about design of tools and broader systems to match the tasks and capabilities of humans – complement each other
- Strength Take home point