From slips and lapses to knowledge-based mistakes: A summary of 'Field Guide to Understanding Human Error' by Sidney Dekker

Hey there safety manager! Are you looking for a book that explains why all of us (even the best of the best) make mistakes? As it turns out that humans are inherently prone to error. In "Field Guide to Understanding Human Error" by Sidney Dekker, you'll learn all about the various ways that humans can (and inevitably will) make mistakes, and how to create systems that are more resilient to those errors.

This book is a must-read for anyone in the safety field who is interested in understanding the role of human error in accidents and incidents. Dekker provides a comprehensive overview of the various types of human error, including slips and lapses, rule-based mistakes, and knowledge-based mistakes. He also discusses how organizational and cultural factors can contribute to errors, and how to design systems that are more forgiving of human error.
Dekker delves into the various ways that humans can make mistakes, and how these errors can impact safety and performance. He discusses the concept of "just culture," which is a system that acknowledges that errors are inevitable and seeks to understand the root causes of those errors rather than simply blaming individuals.
One of the key themes of the book is the importance of understanding the role of context in human error. Dekker argues that errors are often the result of complex interactions between individuals, systems, and the environment, and that it is important to consider these interactions when trying to understand and prevent errors.
Throughout the book, Dekker provides case studies and examples that illustrate the concepts he discusses. These examples come from a variety of fields, including aviation, healthcare, and transportation, and help to bring the ideas to life.

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One example that stands out is the story of a healthcare worker who accidentally administered the wrong medication to a patient. Dekker uses this example to demonstrate the importance of understanding the context in which errors occur, and how a focus on blaming individuals can miss the bigger picture.
Another example that Dekker discusses is the story of an aviation incident in which a pilot made a series of errors that ultimately led to a crash. This example illustrates the concept of "slips and lapses," which are errors that occur when individuals deviate from their normal routine. Dekker discusses how the design of the aircraft and the workload of the pilot contributed to the errors, and how a just culture approach could have helped to prevent the accident.
Overall, "Field Guide to Understanding Human Error" is a must-read for any safety manager looking to improve safety and resilience in their organization. So go ahead, embrace your inner mistake-maker and learn how to create systems that can handle our inevitable errors. Happy reading (and safe managing)!

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