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PEXiS - performance experts in safety - behind human error
the w-hole exercise

At the conclusion of the exercise, you may:

  • Be more aware of typical misunderstandings about how error occurs
  • Be more aware of how assumptions and overconfidence may skew our perception of what is safe.
  • Understand how difficult it is to make safety
  • Consider what similarities and differences do you see between the challenge of the w-Hole and healthcare delivery?


  • After completing all of the five steps of the w-hole exercise you may be more aware of the tradeoffs, goal conflicts and workarounds inherent everyday in healthcare. John Senders, professor at the School of Engineering at the University of Toronto and a leader in safety and human factors described it succinctly:

    "If a hazard exists it should be eliminated; if it cannot be eliminated it should be removed; if it cannot be removed it should be separated; if it cannot be separated it should be warned against. We find that complexity makes creating solutions to hazards difficult. The w-hole exercise demonstrates that simplistic and superficial analyses of problems can easily lead us down a garden path. As the situation changes and becomes more complicated, initial solutions seem ineffective and wasteful. It’s easy to decide that building a fence is an easy way to solve the w-hole problem until the fence is built and the hole remains a hazard. This w-hole is, of course, an analogy to the dangers we face in healthcare. Patient care is fraught with risks; filling the hole as a solution is analogous to refraining from treating patients in order to enhance safety. "

    Situation:


    A large hole lies toward the side of a path. A person falls in the hole.
    Make the case that:

    1. The cause is human error?

    The situation posed is very simple: along the path toward the side, there's a large hole. The event that occurs is also very simple: some one walking down the path falls in the hole and is injured. The situation and event are deliberately as simple as possible. You can add additional factors on to the situation and event sequence as you see fit in order to 'make the case that ...' .

    Your job is to "make the case that -" explains the event or is a solution to avoid similar events in the future.

    The first is (1) Make the case that the cause is human error. In other words, your job is to write two paragraphs or so (about a 1/2 page) to explain that the cause of this event is human error. You can base your statement on material you have heard others use when they explain that an event is due to human error, or even words you have said when you use "human error" as an explanation for adverse events in your personal or professional lives. Play "Devil's Advocate" if need be. These do not need to be highly polished responses, but you need to reflect on and try to capture how people 'make this case.'

    You will respond to 4 more "make the case that -" questions. At the conclusion of the exercise, you may be more aware of typical misunderstandings about how error occurs, how assumptions and overconfidence may skew our perception of what is safe.

    see what others wrote


    Make the case that:
    2. The solution is to put up a sign.


    Specify what the sign should say.

    see what others wrote


    Make the case that:
    3. The solution is to put a fence around the hole to protect people from themselves


    see what others wrote


    Make the case that:
    4. The solution is to ban travel on the path.




    Make the case that:
    5. The solution is to fill in the hole.


    Specify how this may be difficult


    Consider:


    Why is it difficult to maintain safety?

    What similarities and differences do you see between the challenge of the w-Hole and healthcare delivery?



















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