Reducing Errors

Human Performance Training

Accidents?

http://www.youtube.com/watch?v=Qf_LWq88H5I

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

• Human Error

• Willful Violation or Rules/Maliciousness

• Equipment Failure

• Act of God

Why do Accidents Happen?

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

What is an Error?

• 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

What is Human Performance?

• 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

Human Error Data

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

• 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

How Errors Occur

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Familiarity (w/ task)Low High

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Low

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Inattention

Misinterpretation

InaccurateMental Picture

1 in 10,000

1 in 1000

1 in 2

Willful Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience

What an Error is NOT!

Unwanted act or behavior overlooked or

encouraged to achieve goal

You get what you accept!

Condoned Behavior

Condoned Behavior

Condoned Behavior

Task Demands• Time Pressure• Irrecoverable acts• Simultaneous multiple

tasks• Monotonous actions

Error Likely Conditions

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

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

Error Defenses/Barriers

Defense-in-Depth

Reason, J. BMJ 2000;320:768-770

CommunicationTrainingTools &

EquipmentPPE

What other “pieces of cheese” can you think

of?

Event!

• Job Hazard Assessment/Pre-Job Brief

• Self Checking (STAR)

• Peer Checking

• 3 Legged communication

• Situational Awareness

• Questioning Attitude

• Stop When Unsure

Error Prevention Tools

• 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

Job Hazard Assessment / Pre-Job Brief

• 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?

S.T.A.R – Self Checking

• A “second set of eyes” to detect and prevent errors.

• To be used when performing critical work prior to taking action.

Peer Checking

• Used during the execution of critical steps to formalize communication.

• Repeat-back should be used when speaking with Operating entities.

• Ensures mutual understanding

Three-Legged Communication

http://www.youtube.com/watch?v=AHx7xYNdha0

• Continual assessment of surroundings

• Recognize changes in job scope/conditions

• Recognizing changes in behavior

Situational Awareness

See the Big Picture

http://www.youtube.com/watch?v=H2QALNgmL2s

• Stop, look, and listen – proactively search for uncertain or unfamiliar situation

• Gather information – ask questions … don’t assume

Questioning Attitude

• Look for indicator words such as “I think”, “it looks like”, “it should be”, “it normally is”, “I guess”, …

• 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!

STOP When Unsure

Feedback and Reinforcement

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

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