Cognitive error analysis in accident and incident investigation in safety-critical domains
A database of 10 years' worth of medical incident data gathered in an Edinburgh Intensive Care Unit was analyzed using the proposed cognitive error analysis approach. In the second live case study, the error analysis approach was evaluated in the field by applying it to incident reporting data that was collected with a newly implemented incident reporting scheme in a Glasgow Neonatal Intensive Care Unit. The insights gained by analyzing the Edinburgh incident scheme were used to inform the design and implementation of the Glasgow incident scheme as part of the unit's existing safety management. Since both were local incident reporting schemes, it was seen as an important factor for its success to take the local context and conditions into account while situating the cognitive error analysis approach as part of these hospitals' safety management strategies. The evaluation of this incident reporting and analysis framework demonstrated the benefits of a structured, psychological “human error” analysis approach that centres on the human aspect of the incident, without isolating it from its context. It is argued that not only could the understanding of the underlying error mechanisms be improved for individual incidents, but the generation of safety recommendations could be supported, and these could then also be evaluated as to their impact on the human "in the loop". The resulting error analysis models could further be used as basis for comparing competing analyses, and also improve analysis traceability by documenting the analysis process and its resulting safety recommendations. Further work is needed in providing "best practices" for the application of the cognitive analytical framework. Further work is also needed in formalizing a way to situate the cognitive error analysis approach within the investigation of local work system factors in the search for the overall incident and accident causation. This thesis aims at demonstrating the benefits of grounding the analysis of human error as part of incident and accident reporting in a cognitive theoretical framework. This will provide the means and the vocabulary to reason about alternative causal hypotheses while also acting as a tool to document and communicate the psychological analysis of human error and its resulting safety recommendations. This approach is proposed as complementing the analysis of human error data by means of error taxonomies grounded in psychological theory.