Journal of Surgical Simulation 2017; 4: A: 3 - 3

Published: 19 January 2017


Oral presentation

Special Issue: Damage limitation - minimising unintentional harm: complexity, error, team working and human factors

John Kinnear
Corresponding author: John Kinnear, Postgraduate Medical Institute, Anglia Ruskin University, Bishop Hall Lane, Chelmsford CM1 1SQ, UK. Email:


Error has been treated as a science in high risk industry for a long time, but many models of error imply linear determinism. While this may be true for some error, in healthcare it seldom is. An approach is taken where systems error, resulting from behaviours of the collective, is separated from systematic error, which is the result of a flawed decision-making process. Unfortunately, most metrics to control the occurrence of error are aimed at systems error, and demonstrate that error occurrence is a random process with unclear attribution. Root causation of many errors may lie at the level of individual performance, and examples are given of how clinical decision-making is subject to systematic bias. In most circumstances the use of heuristics in decision-making helps us to make rapid decisions based on pattern recognition. However, when this occurs in an unpredictable environment, then incorrect assumptions are likely to end in error. Some potential solutions are presented, which include training to deal with low validity environments (simulation-based learning), use of cognitive aids, and developing collective competence so that individual decision-making is not relied on. 


error; healthcare; simulation-based learning; human factors; complexity

Additional Information

This presentation was given at the 6th Annual Homerton Simulation Conference: Safety Engineering and Simulation in Healthcare, Homerton University Hospital, London, UK, on 1 December 2016.

Conflicts of interest: none declared.