The Pharmaceutical Journal
Vol 269 No 7220 p580
19 October 2002

This article
Reprint
Photocopy

UK medicines information

An air traffic control perspective

A key area of concern within error prevention is the study of human error, to minimise its impact on system safety, said Susie Foley, human factors analyst, National Air Traffic Services (NATS). Historically, safety critical environments such as air traffic control have invested substantial resource in improving systems to ensure extremely high levels of reliability. With increasingly reliable systems and reduced staffing, human error now makes a far greater contribution to overall error than do system failures. In the highly defined and regulated air traffic environment, over 90 per cent of operational failures are human errors.
In collecting information about errors that have occurred it is important to promote a “just culture”. This allows for a fair and consistent approach to error reporting, as opposed to a “blame culture” which victimises the individual responsible without necessarily learning from the mistake, or a “blame-free culture” which implies a lack of responsibility for a professional’s actions.
In analysing errors that have already occurred, NATS looks to identify errors and to understand why they occur. More specifically, it is important to understand the conditions under which errors occur and the relative risk posed by different error types. Since investment to provide corrective action may not be easy to come by, it is important to prioritise areas to target too. Finally, potential risk reduction interventions should be identified together with methods to track the success of these interventions.

  * PDF files on PJ Online require Acrobat Reader 4 or later.