Risk Management: Human Error, Rule-Based Behavior, and Just Culture

This report provides a comprehensive analysis of human error within the context of risk management. It begins by defining human error and exploring various detection and recovery approaches, emphasizing the importance of identifying and mitigating such errors in the workplace. The report then delves into the advantages and disadvantages of rule-based behaviors, highlighting the significance of openness and transparency in managing errors. It contrasts the person and system approaches to error management, providing examples and critical analysis of each. The report also discusses the concept of a 'just culture' and its role in fostering an environment where individuals feel safe to report errors, with a focus on learning from mistakes. The report concludes with a discussion of specific cases and the practical implications of implementing a just culture, ultimately aiming to improve workplace safety and organizational justice.

Module Title: Managing Risk
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INTRODUCTION
Human errors are the error which is not having the intention commit a
mistake along with not having the desired by the specific set of rules and
regulation. The external observer that has led the task outside the system in its
acceptable limits. For more proper understanding it can be stated that their
deviation has been taken place without having intension, expectation or any
desirability. The report will have understanding of human error’s detection along
with recovery approaches. The more understanding regarding the term can be that
the error that has been taken place when all the planned sequence failed to have
achievement over intended outcome It will also have the inclusion of advantage
and disadvantage of rule-based behaviours which have appreciation of openness
and transparency to manage the errors. This will help in proper understanding of
application of knowledge in the process of achieving organizational justice.
MAIN BODY
Understanding of human errors along with detection and recovery approaches
Human errors are, most of the time being cited as the causes of accidents
when all the remaining factors are being eliminated. It is a complicated task to have
a clear definition of human errors. The more understanding regarding the term can
be that the error that has been taken place when all the planned sequence failed to
have achievement over intended outcome. These are this error which cannot be
eliminated the workplace, but if the typical error can be identified, it can
substantially be reduced. As per the traditional point of view human error is being
an attribution after the fact which is being related to people, tools, task and the
operating environment. The human errors have been regards as the action errors
which is further categorised as the slips or thinking errors. Such errors have
deliberate actions which can have adoption of incorrect course of actions. The
intensification of human error can be done through “Swiss cheese” model, as per
the suggested model there are various internal defences along with atypical
condition which is having prevention of disease (Denison, Yan and Butler., 2019).

There are many holes in the slices of Swiss cheese which is having the
continuous open, closing and reallocation. This make permit for the trajectory
accident opportunities. The next is about the human factors that have the
evolvement in dynamic processing for production and understanding language.
The human factors and the personnel error along with the malfunction along with
deficit financing and further more aircraft structure. The next identification is
regarding the cognitive failure which has been predicted due to unsafe behaviour
and the micro-level of accidents among the worker. Rule-based behaviours have
the refers over the situation in which were the use of the particular disregard of the
particular rule along with assert of rules in an undesired outcome. This means that
there is the existence of specific rules and regulation which can be appropriated in
one composition so may be inappropriate in another one.
There is a various factor which is leading to human errors such as the skill-based
behaviours without having conscious control. The rule-based behaviours which are
being structured by feed-forward control. The lack of knowledge regarding
unfamiliar situations. The rule based behaviour in which the person have to follow
remembering the written and rules of communication.
Evaluating of perceptions of unsafe acts.
The explicative model regarding the behaviours of unsafe work to have the
revelation over the mechanism which is contributing behaviours of the individual
the workplace. The human error can be viewed with the two ways which can be
termed as the personal approach and the system approach. Both models have the
error causation along with it gives rise to different philosophies of error
management. There is importance for understanding these implications. It will help
in coping the ever mishaps risk in the clinical practices. The two approaches have
the problem of fallibility of human that is the person and system approach. In the
person approach there is long-standing and widespread approach which is
focusing on unsafe acts that are errors and procedural violations. It has been
analysing the unsafe acts as arising primarily from aberrant mental processes such
as the inattentiveness, inadequate motivation negligence and recklessness. This
counter measures will help in reducing the unwanted variation in human behaviour.

Followers to have the approach will tend to have treat error such as moral issues
as having the assumption that bad things happen to bad people.
The system approach has the fallibility and errors in human are expected even in
the best-organised company. In such approaches the errors are seen as the
consequence for the cause (Hillson., 2017). This has the inclusion recurrent error
traps in the organizational workplace and process. As the per the
countermeasures, there cannot be any changes in the human condition. But there
can be changes in which the social work which will turn out the idea of central
system defence. All the technologies which are hazardous possess barriers as the
barriers and safeguards. The situation where the adverse condition takes place the
first note is not about who is blundered; it is about how and why the defence
system has been failed (Sawhney, Marks and Black., 2016).
Exceptional evaluation of system approach and person approach supported with
relevant examples.
Having the blame over the individual is more satisfying than targeting the regarding
institution. Propel in the organisation are considered to have the capability of
understanding between the safe and unsafe mode so the time when to condition
turn wrong the individual will be responsible (Ang., 2018). There are various
drawbacks of the particular approach as it is ill-suited to the domain of medical line.
The adequate level of the risk manageable depends on the establishment of
reposting culture. The time organisation fails to have the talented analysis of any
mishap, incidents, and it will out to be uncovering the current error traps and the
fall over it. In the reporting culture trust has been identifying as the key element
over the one processing collective understanding between the blameless and
blameworthy actions. By the implementation of approach there is puniness of more
excellent safety and removing the error provoking properties within the extensive
system (Kinsey., 2017).
In the system approach defences, barriers and safeguards occupy as the critical
position in the system approach. The higher level of technologies has a different

layer of defensible layers such as the physical barriers, Automations and the
respective shutdowns. All the technologies which are hazardous possess barriers
as the barriers and safeguards. The situation where the adverse condition takes
place; the first note is not about who is blundered, and it is about how and why the
defence system has been failed. There are many layers of slices with the
continuation of opening shutting and shifting of various location. There can be two
different reasons for the holes in defences that is active failures and the underlying
conditions. The respective are explained such as the active failures are done by
people who are in direct contact with systems such as the slips, lapses mistake
and the procedural vasodilatation. For example- the operates have followed the
wrong procedure and have switched off the successive safety system which has
created the catastrophic explosion in core (Amalberti and Vincent., 2019).
On the other hand, in underlying conditions the decision has been taken by the
blundered, designer or the higher authority. Latent conditions may be dormant
within system for years before they combine with active failures and local triggers
to create an accident opportunity. Unlike active failures, whose specific forms are
often hard to foresee, underlying conditions can be identified and remedied before
an adverse event occurs.
Critical analysis of rule-based behaviour identifying pros and cons of rule-based
behaviour
Rule-based behaviours have the refers over the situation in which were the use of
the particular disregard of the particular rule along with assert of rules in an
undesired outcome. This means that there is the existence of specific rules and
regulation which can be appropriated in one composition so may be inappropriate
in another one. As the application of the inappropriate rule occurs when rule has
been worked over the previous occasion so it can be applied to the similar situation
with the having the incorrect expectation that it will work (Cleden., 2017). On the
other hand, some time the rules are inappropriate there is upcoming of the adverse
outcomes. The desired outcome cannot be delivered with the application of
inappropriate rule. This will also lead to having created the incorrect knowledge or
the first rule any became have the wrong following along with challenges that have

not been adequately managed. The advantage and the disadvantage of the rule-
based behaviour are such as the advantages are there is no need for the
understanding of the reasoning beginning the step. The courses of actions as the
expert backing along with threat it has the level of consistency. On the other hand,
the disadvantage is they can be termed as more time-consuming and creates
unthinking compliance. They cannot apply to every situation and lead to risk of
being wrong procedural selection (Mohanna and Chambers., 2018).
Just culture is the concept and philosophy which balance the need of open and
honest reporting environment. It requires the change in working style that helps in
reducing the error. In a just culture, both the organisation and its people are held
accountable while focusing on risk, systems design, human behaviour, and patient
safety (Aven., 2017). There are certain types of error and the human error cameo
on the top, and there are some other errors such as instrumental errors which
affect the accuracy in the work. There are several measures of just culture are the
constant concern about the possibility of failure and the ability to adapt the
unexpected errors, ability to concentrate on the task while having a sense of the
big picture. Some cases are discussed as follows -One nurse select the wrong way of
medication, and another nurse gave the wrong drug and causing heart failure. The
nurses did not do it knowingly. It was happened lack of training. They did not have
enough knowledge of right medication and drug. After this incident proper training
were provided to nurses. The training was about medication and drug, when to
give medication, what drug should be given. They were not allowed to work until
they learnt. Only After the training they were allowed to work. The nurses took
training seriously and they learnt properly. It was a big mistake that taught
organisation that they should not get work done without training. These types of
mistakes can destroy organisation image. So we can say that just culture is
learning culture that is constantly improving and oriented towards patient safety.
and These are the clear case of human errors, and also this case addresses just
culture that aware the employees about working with accuracy and also the error-
free work.

just culture includes many characteristics. Just culture helps in create an
environment where individual feel free to report errors and help the organisation to
learn from mistakes. This is main characteristics of just culture. Every human can
commit mistake unknowingly but that does not mean that he has committed crime.
Mistakes can be improved. As it is said we learn from our mistakes. Mistakes
should be consider as learning opportunity. In system of just culture, discipline is
linked to inappropriate behaviour rather than harm. This allows for individual
accountability and promotes a learning organisation culture. In this system honest
human mistakes are taken as learning opportunities for organisation and its
employees. Employees can learn through mistakes. Just culture give chances to
learn. Another characteristic of just culture is staff are not punished for action,
omission and decision taken by them that are commensurate with their experience
and training but where gross negligence, wilful violations acts are not tolerated.
Safety is a another feature of just culture. It helps in report about mistakes so that
corrective actions can be taken at right time. Just culture helps in boost confident
among employees that will help in achieve organisational goals. Employees works
in better way with confidence. Just culture teaches us to shift our attention from
retrospective judgement of others, focused on the severity of the outcome.
Establishing a just culture within the organisation requires action on three fronts:-
building awareness, implementing policies that support just culture and building
just culture principle into practices and processes of daily work. The more
significant organisations are completely strict about the accuracy and encourage
the employees by giving proper training, and it also ensures the safety of
employees as well as of the company. Just culture not only identifies the action but
also it is accountable to each other which gives the positive outcome (Paul, Sarker
and Essam., 2015). In a system of just culture, discipline is linked to inappropriate
behavior and also allows for the individual accountability and promotes the organization
culture.
Organisational justice deals with how the employees view the work environment
and fairness in the place of employment. There are three types of justice which are

Organizational, procedural and Distributive justice which deals with the fairness,
procedure and the outcomes from the process. The people are just focused on the
work and the quantity but not on the performance and this impacts on the company
productivity. So, the company gives the training for the development of the
employees so that the employees will give the error-free work and also helps the
company in giving the growth and success to the company. The best application of
organizational justice is to make the decision and also performance through the
direction and routines (Carter., 2018).
CONCLUSION
From the above report, it can be concluded that It is a challenging task to
have a clear definition regarding human errors. The more understanding regarding
the term can be that the error that has been taken place when all the planned
sequence failed to have achievement over intended outcome. The person
approach and system approach are the models for error causation along with it
gives rise to different philosophies of error management. There is importance for
understanding these implications for coping the ever mishaps risk in the clinical
practices. The rule method has the advantage and disadvantage that there is no
need for the understanding of the reasoning beginning the step and applicable at
every situation and lead to risk of being wrong procedural selection, respectively. It
also summarises about the appreciation of openness and transparency to manage
errors and exceptional knowledge of application of just culture and at last the
demonstration of application of knowledge of the process of achieving
organisational justice.
REFERENCES
Books and journals
Hillson, D. and Murray-Webster, R., 2017. Understanding and managing risk
attitude. Routledge.
Hillson, D., 2017. Managing risk in projects. Routledge.
Ang, B.S., 2018. Approach and Assessment of Osteoporosis: Identifying and
Managing Risk. The Singapore Family Physician, 44(3), pp.7-10.

Amalberti, R. and Vincent, C., 2019. Managing risk in hazardous conditions:
improvisation is not enough. BMJ quality & safety, pp.bmjqs-2019.
Cleden, D., 2017. Managing project uncertainty. Routledge.
Mohanna, K. and Chambers, R., 2018. Risk matters in healthcare: communicating,
explaining and managing risk. CRC Press.
Paul, S.K., Sarker, R. and Essam, D., 2015. Managing risk and disruption in
production-inventory and supply chain systems: A review. Journal of
Industrial & Management Optimization, 12(3), p.1009.
Carter, D.J., 2018. Managing Risk Around Upstream Services.The Australian
Hospital & Healthcare Bulletin.
Aven, T., 2017. A conceptual foundation for assessing and managing risk,
surprises and black swans. In The Illusion of Risk Control (pp. 23-39).
Springer, Cham.
Kinsey, S., 2017. Managing risk. In The International Business Archives
Handbook (pp. 356-381). Routledge.
Sawhney, S., Marks, A. and Black, C., 2016. Discharge after acute kidney injury:
recognising and managing risk. Clinical Focus Primary Care.
Denison, D.V., Yan, W. and Butler, J.S., 2019. Managing Risk and Growth of
Nonprofit