Accidents? http://www.youtube.com/watch?v=Qf_LWq88H5I http://www.youtube.com/watch?v=jvaLRabHQ3c&feature= related
Human Error Willful Violation or Rules/Maliciousness Equipment Failure Act of God Why do Accidents Happen?
An unintentional deviation from desired performance due to a mistake, oversight, misunderstanding, lack of awareness, lack of knowledge, miscommunication, lapse or slip. What is an Error?
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 What is Human Performance?
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 Human Error Data
Exercise 1 – Count the Fs FINISHED FILES ARE THE RESULT OF YEARS OF SCIENTIFIC STUDY COMBINED WITH THE EXPERIENCE OF YEARS
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?
Maybe we just need to Focus … And we won’t make errors
Exercise 3 – Count the Passes http://www.youtube.com/watch?v=Ahg6qcgoay4
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 How Errors Occur
Source: James Reason. Managing the Risks of Organizational Accidents, 1998. KB Patterns RB If - Then SB Auto Familiarity (w/ task) LowHigh Low Attention (to task) Inattention Misinterpretation Inaccurate Mental Picture 1 in 10,000 1 in 1000 1 in 2
Willful Violation: Deliberate, intentional acts to evade a known policy or procedure requirement for personal advantage usually adopted for fun, comfort, expedience, or convenience What an Error is NOT!
Unwanted act or behavior overlooked or encouraged to achieve goal You get what you accept! Condoned Behavior
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 Error Defenses/Barriers
Defense-in-Depth Reason, J. BMJ 2000;320:768-770 Communication Training Tools & Equipment PPE What other “pieces of cheese” can you think of? Event!
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 Job Hazard Assessment / Pre-Job Brief
S TOP – Is my attention focused on the task? T HINK – What action am I about to perform? A CT – Am I performing correctly? R EVIEW – Did I get the expected results? S.T.A.R – Self Checking
A “second set of eyes” to detect and prevent errors. To be used when performing critical work prior to taking action. Peer Checking
Used during the execution of critical steps to formalize communication. Repeat-back should be used when speaking with Operating entities. Ensures mutual understanding Three-Legged Communication http://www.youtube.com/watc h?v=AHx7xYNdha0
Continual assessment of surroundings Recognize changes in job scope/conditions Recognizing changes in behavior Situational Awareness See the Big Picture http://www.youtube.com/watch? v=H2QALNgmL2s
Stop, look, and listen – proactively search for uncertain or unfamiliar situation Gather information – ask questions … don’t assume Questioning Attitude Look for indicator words such as “I think”, “it looks like”, “it should be”, “it normally is”, “I guess”, …
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! STOP When Unsure
Feedback and Reinforcement People achieve high levels of performance based largely on the encouragement and reinforcement received from leaders and peers.