Femke van Rijn
Summary slides Human Error
December 2019
Human Error
Lecture 1
Ernst Mach (1905): ‘’Knowledge and error flow from the same mental resources.’’
Human modes of control:
- Automatic information processing (system 1)
- Controlled or conscious information processing (system 2)
Which system you use, depends on attention: bringing information to awareness.
Where we direct our attention depends on expectations.
Models of attention:
Spotlight metaphor: the focus of attention is directed at one location and everything within
this ‘’beam’’ is attended and processed
Zoom lens metaphor: our focus of attention can be narrowed or widened, attention can be
distributed over a large area of the visual field or in a small focused area
The human eye has rods to detect movement, and cones to detect color and detail. When we see
movement, we can direct our attention to it.
Our perceptual system has a limited capacity: it’s limited to one small spatial area and one source of
sound. This is an effective way to deal with a complex environment.
But we are capable of multitasking: divided attention
- Cocktail party effect
- We’re not very good at switching attention, especially when in the same modality
Our working memory is our consciousness, it allows us to pull something out of the long-term
memory. It has a limited capacity: 80-95% is unconsciously processed (system 1).
We make associations.
- Unconscious
- Can lead to illusions
The use of heuristics (mental shortcuts) can lead to biases (systematic judgment errors). But we need
it to prevent overload, and with these we can handle complicated and new situations quite well.
- Confirmation bias = we selectively see/remember what we want to see/remember, what fits
with our beliefs
- Example: the crowd of Trump’s inaugural speech
- It’s evolutionary efficient and generally helpful, but not always
- When you are not aware of this, you cannot change it
Self-control = overriding/altering your own thoughts, emotions or behaviors
- The ability of system 2 to override system 1
- Impulse control
- But doesn’t always work: we have the tendency to choose the unhealthy snack when we are
occupied with something else
- Multi-tasking affects self-control
Ego-depletion = a state in which people are temporarily less successful in self-control
1
, - Example: getting a pizza after an exam
- Linked to the glucose level in the brain
- Effects of judges’ decision making: more approval after a break
Success of self-control depends on:
Individual differences
Situational demands
Motivation
Your belief in ego-depletion? (Baumeister experiments: not replicable)
Since we are associative and have limited resources, can we trust our own judgments?
2 approaches:
- Biases and heuristics approach: no, we can’t (Tversky & Kahneman)
- Naturalistic decision making approach: yes, we can (Obama & Gary Klein)
Firemen have expert intuition: intuition activates an action plan
Recognition Primed Decision making (RPD) model (Klein):
- A situation generates cues, so you recognize patterns that activate action scripts. We access
these by mental simulations, using our mental models.
Expert intuition is a kind of implicit knowledge, you cannot explain this knowledge yourself.
We all have expertise in many domains, like crossing the street our reading our partner’s mood.
- When we have expertise, we can trust our own judgments
Experts fail when true skill lacks: insufficiently predictable environment and/or insufficient
opportunity to master skill.
Lecture 2
Basic skills to execute a surgical procedure:
- Motor skills
- Roadmap (surgical anatomy and procedures)
- Judgment and decisions -> unexpected, unknown, uncontrolled, leads to most errors
(adverse events or near misses)
Adverse event = an injury that might have resulted from medical management
Non-preventable: due to disease or treatment
Preventable: due to error
Near miss = a medical error that could cause injury but does not
Intercepted near miss
Non-intercepted near miss
Pressures in the operating room:
- It has to be now
- It has to be good
- It has to end
There is a lot of variation in patients and diseases. The perfect textbook patient doesn’t exist. It’s not
black and white but in between.
Physician-patient paradox = a patient only has one physician, while the physician has many patients
Biases:
Perceptual illusions
2
Summary slides Human Error
December 2019
Human Error
Lecture 1
Ernst Mach (1905): ‘’Knowledge and error flow from the same mental resources.’’
Human modes of control:
- Automatic information processing (system 1)
- Controlled or conscious information processing (system 2)
Which system you use, depends on attention: bringing information to awareness.
Where we direct our attention depends on expectations.
Models of attention:
Spotlight metaphor: the focus of attention is directed at one location and everything within
this ‘’beam’’ is attended and processed
Zoom lens metaphor: our focus of attention can be narrowed or widened, attention can be
distributed over a large area of the visual field or in a small focused area
The human eye has rods to detect movement, and cones to detect color and detail. When we see
movement, we can direct our attention to it.
Our perceptual system has a limited capacity: it’s limited to one small spatial area and one source of
sound. This is an effective way to deal with a complex environment.
But we are capable of multitasking: divided attention
- Cocktail party effect
- We’re not very good at switching attention, especially when in the same modality
Our working memory is our consciousness, it allows us to pull something out of the long-term
memory. It has a limited capacity: 80-95% is unconsciously processed (system 1).
We make associations.
- Unconscious
- Can lead to illusions
The use of heuristics (mental shortcuts) can lead to biases (systematic judgment errors). But we need
it to prevent overload, and with these we can handle complicated and new situations quite well.
- Confirmation bias = we selectively see/remember what we want to see/remember, what fits
with our beliefs
- Example: the crowd of Trump’s inaugural speech
- It’s evolutionary efficient and generally helpful, but not always
- When you are not aware of this, you cannot change it
Self-control = overriding/altering your own thoughts, emotions or behaviors
- The ability of system 2 to override system 1
- Impulse control
- But doesn’t always work: we have the tendency to choose the unhealthy snack when we are
occupied with something else
- Multi-tasking affects self-control
Ego-depletion = a state in which people are temporarily less successful in self-control
1
, - Example: getting a pizza after an exam
- Linked to the glucose level in the brain
- Effects of judges’ decision making: more approval after a break
Success of self-control depends on:
Individual differences
Situational demands
Motivation
Your belief in ego-depletion? (Baumeister experiments: not replicable)
Since we are associative and have limited resources, can we trust our own judgments?
2 approaches:
- Biases and heuristics approach: no, we can’t (Tversky & Kahneman)
- Naturalistic decision making approach: yes, we can (Obama & Gary Klein)
Firemen have expert intuition: intuition activates an action plan
Recognition Primed Decision making (RPD) model (Klein):
- A situation generates cues, so you recognize patterns that activate action scripts. We access
these by mental simulations, using our mental models.
Expert intuition is a kind of implicit knowledge, you cannot explain this knowledge yourself.
We all have expertise in many domains, like crossing the street our reading our partner’s mood.
- When we have expertise, we can trust our own judgments
Experts fail when true skill lacks: insufficiently predictable environment and/or insufficient
opportunity to master skill.
Lecture 2
Basic skills to execute a surgical procedure:
- Motor skills
- Roadmap (surgical anatomy and procedures)
- Judgment and decisions -> unexpected, unknown, uncontrolled, leads to most errors
(adverse events or near misses)
Adverse event = an injury that might have resulted from medical management
Non-preventable: due to disease or treatment
Preventable: due to error
Near miss = a medical error that could cause injury but does not
Intercepted near miss
Non-intercepted near miss
Pressures in the operating room:
- It has to be now
- It has to be good
- It has to end
There is a lot of variation in patients and diseases. The perfect textbook patient doesn’t exist. It’s not
black and white but in between.
Physician-patient paradox = a patient only has one physician, while the physician has many patients
Biases:
Perceptual illusions
2
