Use error

The term use error has recently been introduced to replace the commonly used terms human error and user error. The new term, which has already been adopted by international standards organizations for medical devices (see #Use errors in health care below for references), suggests that accidents should be attributed to the circumstances, rather than to the human beings who happened to be there.

The term "use error" was first used in May 1995 in an MD+DI guest editorial, “The Issue Is ‘Use,’ Not ‘User,’ Error,” by William Hyman. Traditionally, human errors are considered as a special aspect of human factors. Accordingly, they are attributed to the human operator, or user. When taking this approach, we assume that the system design is perfect, and the only source for the use errors is the human operator. For example, the U.S. Department of Defense (DoD) HFACS classifies use errors attributed to the human operator, disregarding improper design and configuration setting, which often result in missing alarms, or in inappropriate alerting.

The need for changing the term was due to a common malpractice of the stakeholders (the responsible organizations, the authorities, journalists) in cases of accidents. Instead of investing in fixing the error-prone design, management attributed the error to the users. The need for the change has been pointed out by the accident investigators:

A mishap is typically considered as either a use error or a force majeure:

In 1998, Cook, Woods and Miller presented the concept of hindsight bias, exemplified by celebrated accidents in medicine, by a workgroup on patient safety . The workgroup pointed at the tendency to attribute accidents in health care to isolated human failures. They provide references to early research about the effect of knowledge of the outcome, which was unavailable beforehand, on later judgement about the processes that led up to that outcome. They explain that in looking back, we tend to oversimplify the situation that the actual practitioners faces. They conclude focusing on the hindsight knowledge prevents our understanding of the richer story, the circumstances of the human error.

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