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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
Sou
rce:
Ja
mes
Rea
son
. Man
agin
g
the
Ris
ks
of O
rgan
iza
tion
al A
ccid
ents
, 19
98.
KBPatterns
RBIf - Then
SBAuto
Familiarity (w/ task)Low High
High
Low
Att
enti
on
(to
task
)
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???????????
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