3 Why do Accidents Happen? Human ErrorWillful Violation or Rules/MaliciousnessEquipment FailureAct 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 ErrorsUnderstanding How Errors OccurUnderstanding When Errors are Most Likely to OccurUtilizing Tools to:Reduce the Number and Frequency of ErrorsMitigate the Consequences When an Error does Occur
6 Human Error Data 75% - 80% of all OSHA recordable injuries 85% of accidents reported by insurance companies71% of major worldwide airline crashes70% of all operating room anesthetic incidents98,000 deaths per year in US hospitals
7 Exercise 1 – Count the FsFINISHED 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 – ReadingAoccdrnig 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
12 How Errors Occur Misinterpretation/Sensory conflicts Inaccurate mental picture/Pattern matchingIn-attentional BlindnessLimited attention resourcesWe can concentrate on, at most, 2-3 things simultaneouslyLimited working memoryMost 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 PatternsInaccurate Mental Picture1 in 1000RBIf - ThenAttention (to task)1 in 10,000MisinterpretationSBAutoSource: James Reason. Managing the Risks of Organizational Accidents, 1998.InattentionFamiliarity (w/ task)LowHigh
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 BehaviorUnwanted act or behavior overlooked or encouraged to achieve goal You get what you accept!
21 Error Defenses/Barriers Physical or administrative measures put in place to prevent accidents or mitigates their consequences.PPESafety RulesPolicies, Procedures, and GuidelinesTrainingTools and EquipmentOversight Error Prevention Tools
22 What other “pieces of cheese” can you think of? Defense-in-DepthCommunicationTools & EquipmentTrainingPPEEvent!What other “pieces of cheese” can you think of?Reason, J. BMJ 2000;320:
24 Job Hazard Assessment / Pre-Job Brief Identify existing and potential job site hazardsIdentify how hazards will be addressedDiscussion with all job participants to ensure mutual understanding and to ensure all questions and concerns are addressedPre-Job Brief shall cover at least the following subjects:hazards associated with the jobwork procedures involvedspecial precautionsenergy source controlspersonal protective equipment requirementsquestions
25 S.T.A.R – Self CheckingSTOP – 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 surroundingsRecognize changes in job scope/conditionsRecognizing changes in behaviorSee the Big Picture
29 Questioning AttitudeStop, look, and listen – proactively search for uncertain or unfamiliar situationGather information – ask questions … don’t assumeLook for indicator words such as “I think”, “it looks like”, “it should be”, “it normally is”, “I guess”, …
30 STOP When UnsureIf 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.