Tools to Prevent Human Error

Tools to Prevent Human Error

HOWE SCHOOL ALLIANCE FOR TECHNOLOGY MANAGEMENT

ROUNDTABLE

28 February 2012

Steven Jacobs, MBA, R.Ph.

President, Global BioPharm Solutions

President, High Performing Teams, Inc.

Welcome

Roundtable Goals•Understand human error•Explore how the human brain contributes to human error•Utilize tools that prevent errors in the workplace

Logistics

References

• New Research Leads to More Effective Ways of Reducing Human Error in the Workplace (2006). SBWire. Available online at: http://www.sbwire.com/press-releases/sbwire-5110.htm

• Human Error: Causes and Control (2006). George A. Peters, Barbara J. Peters. CRC Press

• Cognitive Systems Engineering (1994). Jens Rasmussen, Annelise Mark Pejtersen, L. P. Goodstein. Wiley publishing company

Facilitator Introduction

Introduction•Name•Background

Module 1:

Exploring Human Error

Apollo

• Fire occurred when the spacecraft cabin was charged with pure oxygen

• Electrical short under the seat of one of the astronauts, and oxygen fed the resulting fire

• Men could not escape because of a poorly designed escape hatch

• It is well known that pure oxygen atmospheres are very dangerous and that escape hatches must be simple to use and open quickly

Challenger

Challenger

• Cold temperatures affected the performance of a seal already stressed due to an inadequate design

• Previous Challenger inspections had shown that the seals were not holding up as intended during launches, and it was known that low temperatures would degrade them further.

Fukushima Nuclear Power Plant - Cause

• Suffered major damage from a 9.0 earthquake and subsequent tsunami on 11 March 2011

• Reactors shut down automatically after the earthquake, and remaining decay heat of the fuel was being cooled with power from emergency generators

• 14-meter tsunami waves disabled emergency generators required to cool the reactors (Reactors designed to handle 6-meter waves)

Fukushima Nuclear Power Plant - Impact

1) Unit 1: Explosion, roof blown off

2) Unit 2: Explosion, contaminated water in underground trench, possible leak from suppression chamber

3) Unit 3: Explosion, most of concrete building destroyed, plutonium leak

4) Unit 4: Fire, water level in spent fuel pools partly restored

5) Multiple trenches: probable source of contaminated water, partly underground, leaked stopped

McNeil-PPC Product Recall History

• McNeil first received complaints of an unusual moldy, musty, or mildew-like odor in its products leading to nausea, stomach pain, vomiting or diarrhea in early 2008

• Cause was chemical called "2,4,6-tribromoanisole (TBA)" which is applied to wooden pallets used for transport

• Products contained small traces of TBA; pallets were traced to a plant in Puerto Rico

McNeil-PPC Product Recall Impact

• Recognized as problem Sep-08• First recall and FDA action Nov-09• Recall widely expanded Dec-09• Lack of action/prevention led to

FDA taking over three J&J plants • Las Piedras, Puerto Rico• Fort Washington, PA• Lancaster, PA

• Cost estimates are in the $50-$100 million range on top of $900 million in lost sales for 2010

Roundtable Activity 1 Instructions

• Work in small groups

• You have three (3) minutes

• Use a piece of paper to capture your group’s work

• Decide why each situation was an accident or human error

• Designate a spokesperson to report out group’s decisions

Roundtable Activity 1 Debrief

• Key words?• Define error and

accident• Real-world examples?

Human Error

An inappropriate action or response, by a person,

resulting in an undesired outcome

Question

Which is preferred: error reduction or error prevention? Why?

Behaviors at Work

1 Recall

10 Discards

30 Major Events

600 Deviation Alerts

3,000 Near Misses

300,000 At-risk Behaviors

The Swiss Cheese Effect

Organization• How can we improve work

design, communication, roles and responsibilities, and tasks?

Processes• How can we make processes

more lean, robust, and reliable?

Behaviors• How can we coach people so

they develop the proper mindset and behaviors in response to conditions leading to errors?

Org

anizatio

n

Accidents

Pro

cesses

Beh

avio

rs

Triggers

James Reason (2002) Human Error, Cambridge Press

Question

Why do human errors occur?

Lego Activity


• You have 10 minutes for this activity

• Using only the set of instructions provided, assemble the LEGO object without errors

Roundtable Activity 2 Debrief

• Which groups finished faster with no errors?

• What errors did you encounter?• What, if any, steps needed to be

redone?• What assumptions led to errors?• What could have been done to

speed up the process while also preventing those errors?

Module 2:

The Brain’s Role in Human Error

The Brain

For 60,000 years, designed to:•Recognize and fight DANGER•Survive•Ensure basic needs met

Brain Stem, Cerebellum & Limbic System • “The reptilian brain”

• Controls all vital functions

• Sensory data for threats transmitted to here

• Emotions rule here

• Takes control when threat impairs safety

• Takes control of movements and sequences when attention focus is required elsewhere

• Cannot process complex sequences or information

• Aborts any delegated tasks that cannot be done


• You have five(5) minutes for this activity

• Identify key opportunities in your work area where errors related to the cerebellum might occur

Temporal Lobe

• “The Connector”• Hearing• Long term memory retention• Speech (the language zone)• Decides where to focus attention

based on emotion• Expression Interpreter• Prioritizes people and social

relationships



• Identify key opportunities in your work area where errors related to the Temporal Lobe might occur

Frontal Lobe (Focus Brain)

• “Executive center”• Controls your behaviors• Home to Personality• Higher cognitive functions

occur here• Complex chains of motor

movements are controlled here

• Area responsible for switch tasking as multitasking is not possible

An Example of the Brain in Action…

• Mr. X is driving down a secondary road, Hobart St., at 9:00 PM in an unfamiliar part of town.

• He is late because he promised to pick up his wife at 8:45.

• Mr. X is listening to the hockey game on the car radio, texting his wife, and looking for Front St., where his wife said to turn in order to reach his destination.

• Ms. Y, wearing a dark blue coat and white hat, crosses in the middle of Hobart St without looking. Mr. X does not see her and strikes Ms. Y with his car.

• Police arrive and question Mr. X, who says that he never saw the pedestrian.

• What caused the accident?

Is Multitasking Possible?

See for your self…



• Identify key opportunities in your work area where errors related to the Frontal Lobe might occur

Occipital Lobe

• Short term memory center• Visual center of brain• Receives and interprets images• Rearranges information with

existing information• Discards information• Works in conjunction with other

lobes to process images into meaningful information

• Differentiates color and shape

How can the occipital lobe be fooled: How many letter F’s?

Finished files are the result of years of scientific study combined with the

experience of years.

Continued: Read Out Loud

IIlovelove

Paris in theParis in thethe spring timethe spring time



• Identify key opportunities in your work area where errors related to the Occipital Lobe might occur

Break time

You have 10 minutes

Root Causes of Errors

1. Memory Gap

2. Attention Gap

3. Learning Gap

4. Decision Gap

5. Procedure Gap

6. Resource Gap

Attention Gap

How the work environment affects the mind

Why Errors Occur:• Loss of focus• Reduced alertness• Absence of triggers



• Work together as a group and identify no less than three(3) strategies that could prevent Attention Gap errors

Attention Gap Prevention Strategies

• Chunk tasks• Rotate tasks• Change task schedule• Segregate similar task(s)• Isolate the activity• Minimize distractions• Reduce cognitive load

Cognitive/Mental LoadWhat error traps do you see?

Memory Gap

How the information is used in the course of action

Why Errors Occur:• Exceptions• Insufficient time to incorporate change(s)• Stronger rules dominate• Rigid (“Just do it!”) or contradictory Information



• Work together as a group and identify no less than three(3) strategies that could prevent Memory Gap errors

Memory Gap Prevention Strategies

• Color triggers• Bright triggers• Auditory triggers• Checklists• Job-aid/procedure• Process picture maps• Poka-yoke• Refresher training

Relying on MemoryWhat error traps do you see?

Mental FitWhat error traps do you see?

Learning Gap

Knowing what to do and how to do it

Why Errors Occur:• Ineffective training methodology• Lack of learning outcome verification• Failure to apply coaching



• Work together as a group and identify no less than three(3) strategies that could prevent Learning Gap errors

Learning Gap Prevention Strategies

• Incorporate four-step training scheme: Present – Demonstrate – Apply – Feedback

• Start with easiest and add on complexity

• Use assessments with observable criteria

• Learners need time, coaching and feedback to master the skill

• Stabilize changes and conditions of the task

• Provide ongoing feedback (positive and feedback for improvement)

• Identify and alleviate obstacles

Decision Gap

Using the right information to make the right decision about the right thing at the right time

Why Errors Occur:• Lack of available data• Failure to observe/foresee a problem• Inadequate decision-making process



• Work together as a group and identify no less than three(3) strategies that could prevent Decision Gap errors

Decision Gap Prevention Strategies

• Consider context, need, and strength (consequences)• Include others in process• Pursue responsibility• Keep options open• Use lessons learned• Educate instincts• Consider source credibility• Play devil’s advocate• Eliminate punishment/finger pointing environments

Procedure Gap

Clarity of roles, responsibilities, and instructions

Why Errors Occur:• Inaccurate or missing information • Lack of clarity in procedure/procedural steps• Instructions are not fit for use



• Work together as a group and identify no less than three(3) strategies that could prevent Procedure Gap errors

Procedure Gap Prevention Strategies

• Incorporate graphics• Clarify roles, responsibilities,

actions, and outcomes• Provide specific feedback and

coaching• Determine and set conditions

for success• Alleviate workplace obstacles• Add time or extra breaks

• Check/validate/clarify message• Simplify terminology, simplify

steps• Validate legibility/clarity• Work out task design• Ensure that procedure is

written by operator that has done it

• Examine/ensure quality of hand-offs

Access and EffortWhat error traps do you see?

Documentation Traps

How is this an Ideal Information Flow?

“Spaghetti” information flow

Linear and continuous

Top down, left to right

Defines purpose

Minimizes use of words

Eliminates redundancies

Contextual notes

Tables, key words vs. text

Shrinks to one page

Shapes expectations

Makes limits readily seen

Work Instruction Design

• Map the process• Identify responsibilities, control points• Keep only required information• Keep to one page if possible• Avoid cross references• Keep instructions concise• Minimize use of words• Create context with images• Use color to enforce steps and checks• Keep approvals simple

Resource Gap

Using the proper resources for the right task

Why Errors Occur:• Ineffective communication• Insufficient feedback• Organizational and/or time constraints• Improper ergonomics



• Work together as a group and identify no less than three(3) strategies that could prevent Resource Gap errors

Resource Gap Prevention Strategies

• Clarify roles, responsibilities, actions and expected outcomes• Examine/ensure quality of hand-offs• Provide specific feedback and coaching• Determine and set conditions for success• Alleviate workplace obstacles• Check/validate/clarify message• Simplify steps• Ensure lean operations• Work out task design

Unclear PrioritiesWhat error traps do you see?

ErgonomicsWhat error traps do you see?

“Fit” between people, technological tools, and environments:

•Physical fit

•Mental fit

•Organizational fit

Organizational FitWhat error traps do you see?

What Good Looks LikeWhat do you see?

• Size

• View span

• Distance

• Extension

• Traction

• Strength

Physical Fit What error traps do you see?


• Share an error or near miss that has occurred at your workplace

• Identify error type(s)• List at least 3 strategies that

could be employed in the workplace to ensure this won’t happen again

Activity 14 Debrief

• Was it easier to identify the error trap?

• Were there solutions/strategies that could be followed to prevent those errors in the future?

Planning Tool and Job Aids

Be the Advocate and Catalyst: Make Problems Visible

Identify problems• Problem card

Raise problems• Shared problems• Daily meeting processes• Inclusive behaviors

Solve problems• Inclusion• Impact of solution on other

teams

Human Error Prevention in Action

No U.S. airline had a single fatality in 2010

U.S. carriers fly 10 million flights (700 million passengers) yearly

“In the entire First World, fatal crashes are at the brink of extinction.”

“Dozens of safety improvements have gradually eliminated whole categories of crashes.”

Quotes Source: USA TODAY – Jan. 2010

Summary

• Proactively identify the conditions that lead to human error in the workplace

• Apply an understanding of human brain function toward preventing human error in the workplace

• Use available tools to prevent human error in the workplace• Establish a safe environment for errors and error reporting

Thank you for your time!

Questions

Steven [email protected]

Documents

Tools to Prevent Human Error