A frequent response to an adverse event is to retrain the staff.
However, training is often criticized as a very weak and
inappropriate response to problems, unlikely to result in
significant sustained improvement. That criticism is correct, to
A recent paper discusses the difference between appropriate and
inappropriate training from the human factors standpoint .
Training as the sole or primary intervention may be of marginal
value as system design issues are often part of the problem.
Additionally, training is likely to be inappropriate if the
organization is encountering significant system design issues and
the organization is trying to:
get people to stop using something incorrectly.
fix an error being committed by a number of people.
change innate human characteristics (e.g., increase
get people to remember safety training they previously had.
Training is likely to be more appropriate:
when introducing new devices or systems.
when using simulation to practice procedures or responses to
for sensorimotor skill training, e.g., mentored procedures,
when system issues are comprehensively addressed as part of
the response to the adverse event.
Russ AL, Fairbanks RJ, Karsh B, Militello LG, Saleem JJ, Wears
RL. The science of human factors: separating fact from fiction.
BMJ quality & safety. 2013;22(10):802–8.