Human Error; Human Error Prevention; Human Error Reduction; Error; Human Performance; Human Performance Improvement;
Root Cause Analysis; Corrective Action; Process Improvement


Four Fields of Focus for Human Error Prevention

Concern

Response
Hazards Implement techniques by which to recognize hazards. Eliminate hazards.  Create administrative process, technical process, equipment and personal barriers to prevent and detect error and hazards activated by error and to mitigate the effects of activated hazards.  Implement techniques by which to avoid holes in barriers.   Implement techniques by which to increase the effectiveness of barriers.
Error-Inducing Conditions and Error-Likely Situations Recognize error-inducing conditions and error-likely situations.  Eliminate these conditions/situations.  Use behavioral tools and techniques (for individual contributors, supervisors and managers) by which to counteract error- inducing conditions and error-likely situations.
Inappropriate Risk-Taking Recognize the behaviors that lead to inappropriate risk-taking.  Practice behaviors that lead to conservative decision-making.
Recurrence of Past Errors Implement a field observation and coaching system.  Implement a problem reporting, root cause analysis, and preventive corrective action system.  Implement performance metrics.

Taxonomy of Human Error Causal Factors
Causal Factor Description
Knowledge-based Lack of knowledge of the standard, requirement or need.
Cognition-based
 		 Lack of the appropriate level of cognition; lack of ability to understand, apply, analyze, synthesize or evaluate such as to be able to meet the standard, requirement or need. 
Value-based
Belief-based		 Lack of respect for or acceptance of the standard, requirement or need.
Error-Inducing Condition-based
Error-Likely Situation-based		 Lack of recognition of the condition or situation and/or lack of behavior to counteract the condition or situation.
Reflexive-based Lack of conservative behavior in immediately reacting to a "field stimulus".
Skill-based Lack of dexterity.
Lapse-based Lack of attention.

 © - B.W. (Ben) Marguglio - 2005-2009

Human Error Prevention
BW (Ben) Marguglio

Why this Seminar?

 In addition to discovery and invention, human error prevention can be the greatest contributor to improved productivity, safety and quality. This seminar provides the most current developments in human error prevention.

Audience

 This seminar is designed for anyone whose objective is to improve productivity, safety and quality. The principles and practices of human error prevention are universally applicable regardless of the type of industrial, commercial or governmental enterprise, and regardless of the type of function performed within the enterprise.

Learning Outcomes

Upon completion of this seminar, one will understand:

· Human error prevention terminology;  

· Quality and safety culture and the quality- and safety-conscious work environment;

· The relationships among culture, beliefs, values, attitudes and behavior;

· The total quality and safety function;

· The seven human error causal factors;  

· The four levels of human error;

· The three levels of barriers to human error;

· The four types of barriers within each barrier level;

· Techniques by which to make barriers effective;

· Error-inducing conditions and behaviors by which to counteract these conditions;

· Non-conservative decision thought processes and behaviors;

· Conservative decision thought processes and behaviors;

· Coaching to reduce the recurrence of human error;

· Human error root causes;

· Human error measurement;

· Design and implementation of a Human Error Prevention Program.

Outline

1.   Definitions of human performance and human error

2.   Classifications of human error

3.   Quality and safety culture

4.   The quality- and safety-conscious work environment

5.   The relationships among culture, beliefs, values, attitudes and behavior

6.   The behavior model

7.   The total quality and safety function

8.   The seven human error causal factors with an example and case study to demonstrate their applicability

9.   Human error and barrier models describing the four levels of human error and the three levels of barriers with a case study to demonstrate their applicability

10.   The relationship of barriers to the total quality / safety function

11.   Techniques by which to strengthen barriers in administrative and technical procedures, equipment and humans, with an emphasis on barriers in procedures and training, and with a case study to demonstrate the application of these techniques

12.   Poka yoke

13.   Types of error-inducing conditions and error-likely situations existing in the task demands, work environment and humans and behaviors to counteract these conditions and situations, with examples and a case study to demonstrate their applicability

14. Thought processes and behaviors leading to non-conservative decisions and those leading to conservative decisions, with a case study to demonstrate their applicability

15. Coaching to reduce the recurrence of human error, with coaching exercises

16. Human error root causes

17. Human error measurements

18. Defense in depth

19. Review of the universally applicable principles of human error prevention

20. Review of the elements of a Human Error Prevention Program

Handouts

 ·  Copy of the visual aids
·  Compilation of recommended behaviors to prevent human error
·  Case study and exercise materials
 ·  Certificate of Completion, with Continuing Education Units
Click here to register for the “Human Error Prevention” Seminar
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