1. Why people make sense in broken systems

This course

1 hour of verifiable CPD. Standalone — not part of a numbered series. GDC Development Outcomes A, B and D.

Suggested study time

• Systems, not villains — 18 min
• Traps in the dental day — 20 min
• Speak up, checklists, learn — 17 min
• Knowledge check — 5 min

What human factors is

It is the study of how people actually work: attention, memory, tiredness, tools, layout, culture. It is not an excuse for recklessness. It is how you stop a competent nurse from drawing up the wrong irrigant because two bottles look identical at 6pm.

The Swiss-cheese idea, in practice

One hole (a rushed medical history) rarely causes disaster. Several holes lining up — locum who does not know the software, a similar-named patient, an interruption mid-consent, no read-back — do. Fix the holes you control.

Blame is a weak control

Telling someone to “be more careful” after a wrong-site or wrong-patient near miss does not change the diary, the labelling, or the habit of answering the phone during local anaesthetic. GDC Standards still expect professional accountability. Human factors asks what made the error easy.

Just culture

Distinguish human error and at-risk shortcuts you can redesign, from reckless disregard. Support the person who reported the incident. If you only punish reporters, the next event stays in the car park.