1. Human Performance Training
Reducing Errors

2. Accidents? http://www.youtube.com/watch?v=Qf_LWq88H5I

3. Why do Accidents Happen?
Human Error
Willful Violation or Rules/Maliciousness
Equipment Failure
Act of God

4. What is an Error?
An unintentional deviation from desired performance due to a mistake, oversight, misunderstanding, lack of awareness, lack of knowledge, miscommunication, lapse or slip.

5. What is Human Performance?
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

6. Human Error Data 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

7. Exercise 1 – Count the Fs
FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

8. FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS

9. 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?

10. Maybe we just need to Focus…
And we won’t make errors

11. Exercise 3 – Count the Passes

12. How Errors Occur 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

13. Attention (to task) Familiarity (w/ task) High Low 1 in 2 KB 1 in 1000
Patterns
Inaccurate Mental Picture
1 in 1000 RB
If - Then
Attention (to task)
1 in 10,000
Misinterpretation SB
Auto
Source: James Reason. Managing the Risks of Organizational Accidents, 1998.
Inattention
Familiarity (w/ task)
Low
High

14. What an Error is NOT!
Willful Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience

15. Condoned Behavior
Unwanted act or behavior overlooked or encouraged to achieve goal You get what you accept!

16. Condoned Behavior

17. Condoned Behavior

18. Error Likely Conditions
Task Demands
Time Pressure
Irrecoverable acts
Simultaneous multiple tasks
Monotonous actions
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

19. Error Likely Conditions

20. Error Likely Conditions

21. Error Defenses/Barriers
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

22. What other “pieces of cheese” can you think of?
Defense-in-Depth
Communication
Tools & Equipment
Training
PPE
Event!
What other “pieces of cheese” can you think of?
Reason, J. BMJ 2000;320:

23. Error Prevention Tools
Job Hazard Assessment/Pre-Job Brief
Self Checking (STAR)
Peer Checking
3 Legged communication
Situational Awareness
Questioning Attitude
Stop When Unsure

24. Job Hazard Assessment / Pre-Job Brief
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

25. S.T.A.R – Self Checking
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?

26. Peer Checking A “second set of eyes” to detect and prevent errors.
To be used when performing critical work prior to taking action.

27. Three-Legged Communication
Used during the execution of critical steps to formalize communication.
Repeat-back should be used when speaking with Operating entities.
Ensures mutual understanding

28. Situational Awareness
Continual assessment of surroundings
Recognize changes in job scope/conditions
Recognizing changes in behavior
See the Big Picture

29. Questioning Attitude
Stop, look, and listen – proactively search for uncertain or unfamiliar situation
Gather information – ask questions … don’t assume
Look for indicator words such as “I think”, “it looks like”, “it should be”, “it normally is”, “I guess”, …

30. STOP When Unsure
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!

31. Feedback and Reinforcement
People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders and peers.

32. Questions???????????