Human Performance Training Reducing Errors

Accidents? http://www.youtube.com/watch?v=Qf_LWq88H5I http://www.youtube.com/watch?v=jvaLRabHQ3c&feature=related

Why do Accidents Happen? Human Error Willful Violation or Rules/Maliciousness Equipment Failure Act of God

What is an Error? An unintentional deviation from desired performance due to a mistake, oversight, misunderstanding, lack of awareness, lack of knowledge, miscommunication, lapse or slip.

What is Human Performance? Recognizing That People Make Errors Understanding How Errors Occur Understanding When Errors are Most Likely to Occur Utilizing Tools to: Reduce the Number and Frequency of Errors Mitigate the Consequences When an Error does Occur

Human Error Data 75% - 80% of all OSHA recordable injuries 85% of accidents reported by insurance companies 71% of major worldwide airline crashes 70% of all operating room anesthetic incidents 98,000 deaths per year in US hospitals

Exercise 1 – Count the Fs FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

Exercise 2 – Reading Aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are wirttn, the olny iprmoetnt tihng is that the frist and lsat ltteer be at the rghit pclae. The rset can be a total mses and you can sitll raed it wouthit porbelm.Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. amzanig huh?

Maybe we just need to Focus… And we won’t make errors

Exercise 3 – Count the Passes http://www.youtube.com/watch?v=Ahg6qcgoay4

How Errors Occur Misinterpretation/Sensory conflicts Inaccurate mental picture/Pattern matching In-attentional Blindness Limited attention resources We can concentrate on, at most, 2-3 things simultaneously Limited working memory Most people can reliably remember 5-7 items at a time

Attention (to task) Familiarity (w/ task) High Low 1 in 2 KB 1 in 1000 Patterns Inaccurate Mental Picture 1 in 1000 RB If - Then Attention (to task) 1 in 10,000 Misinterpretation SB Auto Source: James Reason. Managing the Risks of Organizational Accidents, 1998. Inattention Familiarity (w/ task) Low High

What an Error is NOT! Willful Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience

Condoned Behavior Unwanted act or behavior overlooked or encouraged to achieve goal You get what you accept!

Condoned Behavior

Condoned Behavior

Error Likely Conditions Task Demands Time Pressure Irrecoverable acts Simultaneous multiple tasks Monotonous actions Individual Capabilities Unfamiliar with task Illness / fatigue Unsafe attitude toward task Work Environment Distractions / Interruptions Workarounds Changes Personality conflicts Human Nature Stress Habit patterns Complacency Assumptions

Error Likely Conditions http://www.youtube.com/watch?v=jkct10MkKy8

Error Likely Conditions http://www.youtube.com/watch?v=cG07DqewQN0

Error Defenses/Barriers Physical or administrative measures put in place to prevent accidents or mitigates their consequences. PPE Safety Rules Policies, Procedures, and Guidelines Training Tools and Equipment Oversight Error Prevention Tools

What other “pieces of cheese” can you think of? Defense-in-Depth Communication Tools & Equipment Training PPE Event! What other “pieces of cheese” can you think of? Reason, J. BMJ 2000;320:768-770

Error Prevention Tools Job Hazard Assessment/Pre-Job Brief Self Checking (STAR) Peer Checking 3 Legged communication Situational Awareness Questioning Attitude Stop When Unsure

Job Hazard Assessment / Pre-Job Brief Identify existing and potential job site hazards Identify how hazards will be addressed Discussion with all job participants to ensure mutual understanding and to ensure all questions and concerns are addressed Pre-Job Brief shall cover at least the following subjects: hazards associated with the job work procedures involved special precautions energy source controls personal protective equipment requirements questions

S.T.A.R – Self Checking STOP – Is my attention focused on the task? THINK – What action am I about to perform? ACT – Am I performing correctly? REVIEW – Did I get the expected results?

Peer Checking A “second set of eyes” to detect and prevent errors. To be used when performing critical work prior to taking action.

Three-Legged Communication Used during the execution of critical steps to formalize communication. Repeat-back should be used when speaking with Operating entities. Ensures mutual understanding http://www.youtube.com/watch?v=AHx7xYNdha0

Situational Awareness Continual assessment of surroundings Recognize changes in job scope/conditions Recognizing changes in behavior http://www.youtube.com/watch?v=H2QALNgmL2s See the Big Picture

Questioning Attitude Stop, look, and listen – proactively search for uncertain or unfamiliar situation Gather information – ask questions … don’t assume Look for indicator words such as “I think”, “it looks like”, “it should be”, “it normally is”, “I guess”, …

STOP When Unsure If you have a feeling that something is not right – STOP! If you are not sure of the course of action of the outcome of your actions – STOP!

Feedback and Reinforcement People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders and peers.

Questions???????????