Human Error Reduction
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Human Error Reduction © 2011 Talsico International Extract Only These materials remain the property of Talsico International and may not be reproduced or used in any form or for any purpose without the written permission of Talsico International. www.talsico.com Presented by: Susan Lynn
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Transcript of Human Error Reduction
Human Error Reduction © 2011
Talsico International
Extract Only
These materials remain the property of Talsico International and may not be reproduced or used in any form or for any purpose without the written permission of Talsico International. www.talsico.com
Presented by: Susan Lynn
Human Error Reduction © 2011
Talsico [ Healthcare & Pharmas
ü Systems & tools to reduce human errors
ü Work where cost of human error is high
ü Offices [ USA, Australia, Puerto Rico, South Africa
ü Pharmaceuticals [ 9 of Global top 10
ü Clients [ All 7 continents
Human Error Reduction © 2011
What are Human Errors?
“An inappropriate action or response by a person
resulting in an undesired outcome”
Human Error Reduction © 2011
Left Brain, Right Brain Exercise
Ñ
Human Error Reduction © 2011
Key Points
q 70-96% errors…Check the hidden processing – common response: retrain/”punish”?
q Minimize conflictsq Ensure input is in the most appropriate format to achieve desired
output
OutputInput
Human Error Reduction © 2011
Topics What are Human Errors?
– Why “train or punish” doesn’t workError Control Hierarchy
Memory GapLearning Gap
Omission
Categories of Error & Strategies for Prevention
~
Case Study
Human Error Reduction © 2011
Human Error Reduction © 2011
Section 2Memory Gap Errors
(Extract Only)
Human Error Reduction © 2011
Recognition vs Recall
Human Error Reduction © 2011
Recall….Exercise
Ü
Typically < 10% of people
can do this!
Human Error Reduction © 2011
Recognition….Exercise
Typically 100% of people
can do this!
Human Error Reduction © 2011
1Brain uses 2 different processes for
remembering!Recognition - “from a list, point out ..”
Has external starting pointRecall – no external starting point
2 Recognition easier to learn,
less error-prone, more stable than recall.
Where possible, design for recognition rather than recall
3 Recognition – use SOPs, aids, system
prompts, PPMs. Must be accessible otherwise
forces “recall”
Recognition vs Recall
4 Accessible?
Physical Accessibility = “Within Reach”
Cognitive Accessibility = Easy to “Grab” req’d info
Recognition vs Recall – learn to req’d level
Human Error Reduction © 2011
Recognition – Accessibility!
Cognitive Accessibility? Cognitive Accessibility?ü
Process Picture MapsTM
ü
Human Error Reduction © 2011
Auto-sequences
Human Error Reduction © 2011
Habits & Auto behavior– processed differently
Habits & Auto-sequences
Human Error Reduction © 2011
Auto-sequence Exercise
How did it feel?
Human Error Reduction © 2011
Section 5Omission Errors
(Extract Only)
Human Error Reduction © 2011
Assignment – Learning Outcomes
q Rank the following Attention Activators in order of effectiveness: shape, motion, sound, text, color
Human Error Reduction © 2011
Attention Activation– Alertness, focus, goal
Attention Activation
µ ~
Human Error Reduction © 2011
Attention Activators (Types by strength)
1. Sound
2. Motion or change in pattern
5. Text
3. Color
4.Shape
~
Human Error Reduction © 2011
Observation & Suggestions
Tools & case study
Human Error Reduction © 2011
To Err . . . is Avoidable
Human Error Reduction © 2011
Human Error Reduction © 2011
HE Investigation & Diagnostics
InvestigateüEstablish collaborative intentüStructured interview processüFair, consistent, effective
Determine Error Categories
üFocus on relevant area(s)
Diagnose Cause(s) & Explore Recommended
Actions
Human Error Reduction © 2011
1. Analyze “the job” _ Science of H.E.RIdentify Human Error Reduction Opportunities (H.E.R.O)
• Tasks, • Equipment, • Systems,• Workflow, • Physical environment, • Interactions – human to equipment• Interactions – human to human• Paperwork – forms filled• Paperwork – procedures & manuals• Cognitive processes required, • Learning acquisition & assessment• Culture• ….
Identified 30 opportunities.
Many able to be implemented immediately
Human Error Reduction © 2011
2. Redesign Forms, InsertsLengthy & wordy (~43
pgs, ñ text)
Important info “lost” among general body
Error-prone! Time-consuming to fill in &
review ($$)
Original NewShorter & clearer (~25 pgs, textò74%)
Attention Activators for important info!
Paperwork errors ò65%Saved ~1 hr per review
($$$$$)
Human Error Reduction © 2011
3+. Redesign & Integrate Procedures, Instructions… Learning System…for hospital, caregiver, patient
Error-prone! Long, hard to follow,
not “useful”!
New PPMOriginal Procedure More effective
ò66% shorter
0 human errors for 18+ months! (previously ~ 2 ER / mth)
Human Error Reduction © 2011
Talsico International
hank ou
