Human Error Reduction – A Systems Approach

Background In many organizations, the root cause for Human Error is assigned as ‘Lack of Attention to detail’ or ‘Failure to follow procedure.’ Corrective action will involve re-training or discipline. Such approaches do not typically get to the true root cause as to why errors occur, and generally will not prevent a re-occurrence of the issue.

Cross Functional Project Team Established QA Team Leads Operators Training Engineering

Approach The project team set about understanding human error by adopting a more systematic structured approach. The key methodology employed involved ‘Cause and Effect’ analysis and ‘Gap Analysis.’ In addition, an internal training program was developed to provide a greater theoretical understanding of human behaviour and system design.

Step 1 Brainstorm all possible reasons for human error. Step 2 Generate a cause and effect diagram with all potential reasons for error identified. Step 3 Generate a gap analysis study. Critically evaluate each individual error category.

Cause and Effect Diagram

Cause and Effect Categories

Personnel Ineffective Training Focus, motivation and application Suitability for role Shift handover and communication between breaks Repetitive Tasks Work load and multitasking

Methods/Procedures Lacking detailed instruction Inconsistent format No visual images in documentation Poorly written procedures Test method variability Procedures too detailed and difficult to follow

Machinery Reliability of equipment Preventative Maintenance Multiple Settings Equipment Change Control Suitability for task being performed

Materials Staging and Issuing Process Material Flow Identification & Segregation Labelling

Environment Layout of work area Insufficient space Noise and distractions Temperature/Humidity conditions Lighting Ergonomics

Gap Analysis Study

Summary - Human Error Factors Physiological Factors Psychological Factors Environmental Factors Material Flow Segregation and Identification Documentation Design Robustness of Test Methods Multi-tasking & Resourcing Maintaining employee motivation and engagement Communication & Shift Handover Effective system of Training Reporting of errors

Progress to date Checklists and standard methodology developed to serve as a guide in performance of root cause investigations into human errors. Gap Analysis study performed and from this study, corrective and preventative actions implemented to reduce the potential for human error. Training course on the systems approach to human error reduction delivered to key personnel on site.

Next Steps Monitor the effectiveness of ‘Human Error’ Training and system improvements through the analysis of deviation metrics. Continue to employ root cause investigation tools such as Cause and Effect, 5Ys and Fault Tree Analysis in performance of human error investigations. Risk assess target areas for potential for human error and implement appropriate preventative measures. Involve operator input more extensively in human error root cause investigations.

‘If you do what you have always done, you will get what you’ve always gotten’ - Anthony Robbins

Key Content of Training Program Review of Disasters – Human Error Human Error – Facts and Figures Swiss Cheese Model of Error Model of Information Processing Multitasking & Forgetting Error and Documentation Design Deviation reports & OOSs Practical Exercises

Well Known Disasters Challenger Space Shuttle (1986) Bhopal Chemical Plant (1986) Herald of Free Enterprise Ferry (1987) Kegworth Air Crash (1989) Marc Train Crash (1990) Chernobyl Nuclear Accident (1986)

Model of Information Processing (Atkinson-Shiffrin)

The Swiss Cheese model of Error/Accident Causation James Reason

‘We cannot change the human condition, but we can change the conditions under which humans work’ BMJ 2000;320:768-770 J Reason

Learning Styles

Conclusion The key to reducing human error is to have an understanding of the human factors that can contribute to error. Central to this approach is the design of systems and processes that will reduce the potential for error. By adopting a systematic and structured approach, we can go a long way towards reducing the potential for error.

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