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require your attention (distraction), the systems are outdated, there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
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