How To Reduce Human Errors

How To Reduce Human Errors

The Culture Perspective by Karen Zimmermann on Tuesday the 10th of July, 2018.

How To Reduce Human Errors ; The Culture Perspective

“Mistakes are always forgivable, if someone has the courage to admit them.” - Bruce Lee

People make mistakes. We always have and we always will. To be able to answer the question “How To Reduce Human Errors?”, you’ll first need to know WHY we are making mistakes.

Why are we making mistakes?

1. Physiology You may be fatigued, have a low physical condition, feel stressed, have issues at home or you are used to certain routines.

2. Environment Many people require your attention (distraction), the systems are outdated, there is not enough light, the temperature is too high or too low or you are afraid to honestly report issues due to the organizational culture.

3. Task You may have insufficient experience, received incomplete information, are responsible but not authorized to make decisions, or there is a mismatch between the person and the task. The reason why we are making mistakes is that….. we are human beings. You don’t go to work thinking “Today, I feel like making a mistake”. Instead, you go to work, and many different issues require your attention. When trying to solve human errors, we tend to look at the “easy to solve” reasons. You update the procedure, train personnel. Thankfully, this is no longer accepted by the regulatory authorities.

But how do you do proper Human Error Reduction?

The complexity of Human Errors I would like you to meet Brian (not his real name). Brian is a line operator. With his salary and bonus, he provides for his wife and children. Last week, he had a tough conversation with his supervisor. He was disappointed in Brian’s output. Overwhelmed by this pressure, John’s team had missed a blue capsule during line clearance. He noticed this tablet during manufacturing of the next batch; Isotretinoin red/orange colored soft capsules. In a split second, he picked up the capsule and placed it aside. He continued manufacturing without reporting the incident. Of course, this is not acceptable. Brian should have informed his supervisor, a deviation report should have been initiated and followed by a thorough investigation. Yet, his choice is understandable. Reporting this line clearance issue would have resulted in a deviation on Brian’s name, less output and financial consequences affecting his family. The story of Brian is illustrating the complexity of human error reduction. Brian has indicated several times that the old machines are very difficult to clean. It is impossible to guarantee that no tablets or capsules have been overlooked. Yet, no real preventive action has been taken other than additional training and long painstaking checklists. Insufficient torches and mirrors to properly inspect the machines, result in losing time searching for materials. And on that specific day, he also had a massive headache, and not feeling at ease due to his supervisor’s warnings. Conclusion? Brian’s story is not unique. At PCS, this is what we see happening in most organizations: updating procedures hoping it solves the problem. But human error reduction is complex and challenging, it is part of the organizational culture. It requires leadership and an atmosphere of openness and honesty. And as Brian said later on “I do understand that not all issues can be solved at once. But being part of improving the process and getting support makes me feel responsible.” How to continue? You may wish to answer the following questions about your organization: How do we look at human errors? As a symptom, or as errors that should be removed as soon as possible? Are human errors openly discussed and welcomed as opportunities to improve the system? Are managers and supervisors trained on human psychology?

Kind regards, Karen Zimmermann