tools to prevent human error
DESCRIPTION
HOWE SCHOOL ALLIANCE FOR TECHNOLOGY MANAGEMENT ROUNDTABLE 28 February 2012. Steven Jacobs, MBA, R.Ph. President, Global BioPharm Solutions President, High Performing Teams, Inc. Tools to Prevent Human Error. Welcome. Roundtable Goals Understand human error - PowerPoint PPT PresentationTRANSCRIPT
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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.
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Welcome
Roundtable Goals•Understand human error•Explore how the human brain contributes to human error•Utilize tools that prevent errors in the workplace
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Logistics
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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
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Facilitator Introduction
Introduction•Name•Background
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Module 1:
Exploring Human Error
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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
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Challenger
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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.
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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)
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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
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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
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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
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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
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Roundtable Activity 1 Debrief
• Key words?• Define error and
accident• Real-world examples?
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Human Error
An inappropriate action or response, by a person,
resulting in an undesired outcome
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Question
Which is preferred: error reduction or error prevention? Why?
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Behaviors at Work
1 Recall
10 Discards
30 Major Events
600 Deviation Alerts
3,000 Near Misses
300,000 At-risk Behaviors
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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
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Question
Why do human errors occur?
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Lego Activity
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Roundtable Activity 2 Instructions
• You have 10 minutes for this activity
• Using only the set of instructions provided, assemble the LEGO object without errors
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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?
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Module 2:
The Brain’s Role in Human Error
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The Brain
For 60,000 years, designed to:•Recognize and fight DANGER•Survive•Ensure basic needs met
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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
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Roundtable Activity 3 Instructions
• You have five(5) minutes for this activity
• Identify key opportunities in your work area where errors related to the cerebellum might occur
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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
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Roundtable Activity 4 Instructions
• You have five(5) minutes for this activity
• Identify key opportunities in your work area where errors related to the Temporal Lobe might occur
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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
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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?
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Is Multitasking Possible?
See for your self…
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Roundtable Activity 5 Instructions
• You have five(5) minutes for this activity
• Identify key opportunities in your work area where errors related to the Frontal Lobe might occur
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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
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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.
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Continued: Read Out Loud
IIlovelove
Paris in theParis in thethe spring timethe spring time
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Roundtable Activity 6 Instructions
• You have five(5) minutes for this activity
• Identify key opportunities in your work area where errors related to the Occipital Lobe might occur
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Break time
You have 10 minutes
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Root Causes of Errors
1. Memory Gap
2. Attention Gap
3. Learning Gap
4. Decision Gap
5. Procedure Gap
6. Resource Gap
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Attention Gap
How the work environment affects the mind
Why Errors Occur:• Loss of focus• Reduced alertness• Absence of triggers
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Roundtable Activity 7 Instructions
• You have five(5) minutes for this activity
• Work together as a group and identify no less than three(3) strategies that could prevent Attention Gap errors
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Attention Gap Prevention Strategies
• Chunk tasks• Rotate tasks• Change task schedule• Segregate similar task(s)• Isolate the activity• Minimize distractions• Reduce cognitive load
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Cognitive/Mental LoadWhat error traps do you see?
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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
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Roundtable Activity 8 Instructions
• You have five(5) minutes for this activity
• Work together as a group and identify no less than three(3) strategies that could prevent Memory Gap errors
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Memory Gap Prevention Strategies
• Color triggers• Bright triggers• Auditory triggers• Checklists• Job-aid/procedure• Process picture maps• Poka-yoke• Refresher training
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Relying on MemoryWhat error traps do you see?
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Mental FitWhat error traps do you see?
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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
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Roundtable Activity 9 Instructions
• You have five(5) minutes for this activity
• Work together as a group and identify no less than three(3) strategies that could prevent Learning Gap errors
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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
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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
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Roundtable Activity 10 Instructions
• You have five(5) minutes for this activity
• Work together as a group and identify no less than three(3) strategies that could prevent Decision Gap errors
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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
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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
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Roundtable Activity 11 Instructions
• You have five(5) minutes for this activity
• Work together as a group and identify no less than three(3) strategies that could prevent Procedure Gap errors
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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
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Access and EffortWhat error traps do you see?
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Documentation Traps
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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
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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
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Resource Gap
Using the proper resources for the right task
Why Errors Occur:• Ineffective communication• Insufficient feedback• Organizational and/or time constraints• Improper ergonomics
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Roundtable Activity 12 Instructions
• You have five(5) minutes for this activity
• Work together as a group and identify no less than three(3) strategies that could prevent Resource Gap errors
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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
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Unclear PrioritiesWhat error traps do you see?
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ErgonomicsWhat error traps do you see?
“Fit” between people, technological tools, and environments:
•Physical fit
•Mental fit
•Organizational fit
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Organizational FitWhat error traps do you see?
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What Good Looks LikeWhat do you see?
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• Size
• View span
• Distance
• Extension
• Traction
• Strength
Physical Fit What error traps do you see?
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Roundtable Activity 14 Instructions
• 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
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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?
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Planning Tool and Job Aids
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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
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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
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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
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