Memory Failures And Pilot / Atc Performance Errors

One of the recommendations for healthcare organizations to employ in an effort to reduce the number of errors is to advocate for voluntary error reporting nationally while conducting research and developing tools for patient safety. This way, information about errors can be gathered and prevented from reoccurring at health care sites and by health care providers. Voluntary error reporting will act as a warning of potential or actual errors and suggest ways to avoid them in the future.

Instead we can focus on the reason why the person makes the error, and how to reduce the risk of that error to be happening again. Not only that, knowing that making error is humanist can create an environment where individuals are confident that they can report errors or close calls (“near-misses”) without fear of retribution CITATION. For example, if the hospital which the nurse who did a med error is having a culture of safety, the nurse would have no reason to fear of fault, shame, and discipline about the error. She instead should be comfortable to report the error right away to be taken care of, and let the hospital team analyzes the error and find out how to mitigate or prevent future

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

When assessing whether a no fault regime is better than a negligence rule in dealing with the causes and consequences of medical error, it would seem prudent to first understand the meaning of the term “medical error”. Liang defines medical error as ‘a mistake, inadvertent occurrence, or unintended event in health-care delivery which may, or may not, result in patient injury’ (2000, p.542). The consequence of these errors (or adverse events) that lead to patient injury, and the method by which we determine and administer compensation for such injuries, has been the source of heated debate amongst scholars in recent

Cognitive errors of omission and commission are the most common types of medical errors that will happen in the workplace environment.

Medical errors can be defined as errors, adverse events and preventable adverse events. The Institute of Medicine (IOM) defined all three components of medical errors and they are as follows: errors occur when the intended plan of action fails and

Whenever there is an error or miss reporting allows for analysis and identification of potential errors, which can help in improving and sharing of information for safer patient care (Glynda Rees Doyle, 2016).

The third leading cause of death in America may surprise you. Hospitals and healthcare organizations dedicate their branding to reflect a place of hope, comfort, and healing when ones health is compromised. Sadly, medical errors do exists in the realm of healthcare. The National Center for Biotechnology Information defines medical error as “an act of omission or commission in planning or execution that contributes to or could contribute to an unintended result.” Medical errors may include incorrect record keeping, administering incorrect medication to a patient, misdiagnosis, failing to remove all surgical instruments and performing surgery on the incorrect site. The Agency for Healthcare Research and Quality identified eight factors that contribute to the cause of medical errors. These factors include “communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns, technical failures and inadequate policies and procedures.”

Depends on the mistakes, which is why we document everything with the client, is very important not to make any mistakes.

Disclosing medical errors is considered necessary by patients and practitioners. They are advised to disclose in the form of an apology when necessary and appropriate. When a medical error causes damage to the patient, it seen as not acceptable because a patient goes for treatment in order to get better not to get worse therefore it calls for the situation to be addressed. When a medical error is not disclosed, the fellow peers who have witnessed the error must decide whether they should remain silent and keep the error to themselves or reveal the error to the higher up, although it would be in good faith to report the medical error to a higher up, unless it has caused harm or long-term damage to the patient. (Youngson. p. 69) There are many hospitals that the practitioners keep the errors made to themselves and do not disclose the medical errors to the families of patients or the patients themselves. Medical errors become a topic of conversation if the family of a patient or the patient themselves become aware about the error. Medical errors are something that should be disclosed in a good faith manner

In modern aviation, pilot fatigue has become a vital problem that needs urgent intervention. The full effect of fatigue is frequently unforeseen however, many of its harmful effects have been known for a long time. When comparing with individuals who usually have enough rest, individuals who suffer from fatigue act slowly, have difficulties in memory, and are involved in many mistakes. In addition, the negative impact can or may lead to aviation accidents and errors (Caldwell, Mallis, Caldwell, Paul, Miller, & Neri, 2009).

It is worth emphasizing that the ZD concept is doing it right the first time. That means concentrating on preventing defects rather than just finding and fixing them. Unfortunately people are conditioned to believe that error is inevitable; thus they not only accept error, they anticipate it. People are not bothered when few mistakes are made at the workplace. 'To err is human', they say. We as individuals do not tolerate these things and people tend to have dual standards - one for ourselves and one for our work. For instance for a nurse to drop a constant percentage of newborn babies may be considered normal, but what about when our baby is dropped? Is it an issue to be taken kindly? At any rate Crosby believes that most human error is caused by lack of attention rather than lack of knowledge. Lack of attention is created when it is assumed that error is inevitable. He believes that if constant conscious effort is made for everyone to do our jobs right the first time, there will be a great step towards eliminating the waste of rework, scrap and repair that increases cost and reduces individual

Memory facilitates necessary functions in daily life activities, but it is not a perfect mechanism in operation. Goldstein (2011) states that memory is, “…the process involved in retaining, retrieving, and using information about stimuli, images, events, ideas, and skills after the original information is no longer present” (p.116). There are many adaptive functions within the complexities of the human memory system and the interlinked constructs between each function leave room for doubt in the accuracy of recollection. Study of the human mind has opened avenues of discovery on the inner workings of our brains and the resulting knowledge suggests that humans are prone to creating false memories and even remembering things that never actually happened. A great deal of information has been written explaining the nature of memory errors and within the following pages a real-life case offers a glimpse into how recall distortions and memory errors can wield unpleasant consequences. Memory errors can be avoided with a significant effort, but the truth remains that no one is perfect and memories are subject to individual bias.

Human error is a primary factor that makes organisational accidents unavoidable. Human error is defined as a human decision or action in which

According to Rodrigues and Cusick (2012) humans are accountable for approximately 70-80% of aviation accidents (p.156). A majority of these are caused by the different variables associated with human performance. Psychological factors have a key role in a pilot’s everyday responsibility. Some of these traits include: perception, memory, attitude, judgment and decision making, as well as ego (Rodrigues & Cusick, 2012, p. 158-160). These qualities can have drastic effects in commercial aviation if they are not recognized and adjusted accordingly. In this paper I will respond to some questions that are raised in aviation safety: