An illustration of the human involvement in a causal sequence of events. An illustration of the human involvement in a causal sequence of events. The event.

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An illustration of the human involvement in a causal sequence of events. An illustration of the human involvement in a causal sequence of events. The event of human error is decomposed to identify the cognitive task element and the psychological mechanism involved in the error. At this level of detail, an event in the work context activates a particular psychological mechanism which influences the immediate decision task required by the work. A decision error in turn introduces an error in the overt action sequence, with unacceptable consequences for the work goal. Two aspects are essential in the present context. One is that human “error” very frequently will be a link in a sequence, not the origin. Secondly, “errors” can be categorized at different states in the flow. This representation is well suited for failure-mode-and-effect analysis in the interface of technical systems: the various psychological “error mechanisms” are folded on to the cognitive task from which the effects, in turn, are folded on to functional system properties for evaluation of the acceptability of consequences. J Rasmussen Qual Saf Health Care 2003;12:377-383 Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.