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This paper attempts to explore the human factors and systems dynamics of human–machine interaction by reference to the Kegworth aircraft accident. The paper seeks to move beyond the more traditional human factors literature to include research findings from both systems research and crisis management in an attempt to examine the relationships between active and latent failures. The role of human error within complex technical systems is explored and particular emphasis is placed upon the dynamics of latent errors within the management of such systems. The main thesis developed here is that, while there are important cognitive processes at work within accident causation, attention needs to be moved away from the level of the operator to the wider managerial and social frameworks within which individuals work. Copyright © 2000 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: Wristbands are recommended in the UK as a means of verifying patient identity but have been little studied. We aimed to document how wristbands are used in practice., Design: and participants Task analysis of wristband application and use, drawing on qualitative analysis of workplace observation of, and interviews with, clinical and non-clinical staff., Setting: Two acute district general hospitals in northern England., Results: Our findings indicate high levels of awareness amongst clinical staff of local and national policies on wristband use, but some ambiguity about the details therein. In contrast, non-clinical staff such as ward clerks and porters were less aware of policy, although their actions also expose patients to risks resulting from misidentification. Of seven subtasks identified by the task analysis of wristband application and use, three appeared to offer particular opportunity for error. Making the decision to apply, especially in emergency patients, is important because delay in application can delay correct identification. Advance preparation of wristbands for elective admission without the patient being present can risk erroneous data or misapplication. Lastly, utilization of wristbands to verify patient identity was greater in some clinical circumstances (blood transfusion and medication administration) than in others (before transferring patients around the hospital and during handovers of care)., Conclusions: Wristbands for patient identification are not being used to their full potential. Attention to detail in application and use, especially during handover and transfer, and an appreciation of the role played by 'non-clinical' staff, may offer further gains in patient safety.