1. NOE Human Error Reduction: Schering Plough (Brinny )
Donal O’Callaghan & Julie Wade

2. Agenda Definition of Human Error Human Error Data from Brinny
Types of Human Error
Error Reduction Hierarchy
The HEAT Tool
The results to date…..next steps

3. What are Human Errors ?
“An inappropriate action or response by a person resulting in an undesired outcome”

5. NOE Data 2008
33 % of NOEs
Root Cause was
Human Error

6. What did the data tell us?
Human Error NOEs consistently accounted for 33% of total NOEs
Training Common Response – Investigate & Train
Many errors not due to lack of skill or knowledge.
Number of Human Errors were not reducing
Similar issues re-occurred over and over again  re-training is NOT working.
Training can only solve a Human Error when the cause is lack of skill or knowledge

7. ??? Human Error Factors Training 18 %
Statistics indicates that Training was the cause for poor performance in 18% (*) of the case.
What are the their factors affecting human performance?
(*) Often we put training as the solution, but it isn’t. You may ask them « what happens if training was not the solution? ».
When the only solution of training it is a waste of time and money and sense of frustration for the employee or trainer. Refer back to TTT course, train only when required.
As a group, using the key indicators in the participant manual,discuss :
what affects human performance or
how can one factor affect human performance
Wrap-up using the next slide. 18

8. Human Error Factors Training Physical or mental capacity? Recognition
Support?
Clarity of instruction?
Working conditions = Provide time, materials, equipments; allow opportunity to practice to practice and develop skills; allow time to do the job properly
Feedback = Monitor Performance; need to ‘be on the floor’
Recognition support = listen to their concern, encourage them, motivate them, show empathy and address their suggestions to improve their work environment
Clarity of instruction = procedure written for and usable by the employee; provide worksheet that are clear and easy to follow
Physical or mental capacity = modify the working environment to optimise the utilisation of their capacity, minimize distraction, work ergonomic, etc
Clarity of expectation = set clear goals and objectives, improve quality of communication
Clarity of expectations?
Working conditions?
Feedback 18

9. Brinny : Human Error Categories* on Trackwise
Learning Gap – don’t know or don’t understand – no training or poor quality training
Memory Gap – know, but don’t remember – after break, after holidays, long absence – after recent change not reinforced
Application – know, but did not use correctly – over burden - stressed
(*Source Talsico ; www. Talsico.com )

10. Brinny : Human Error Categories* on Trackwise
Attention- know but distracted by other factors – wrong position – visual inspection units wrong place
Omission – know, but missed a step – overburden, pressure
Decision – incorrect decision is made – decisions are emotional why was wrong one made?
Procedure – inconsistent performance due to poorly documented procedure
(*Source Talsico ; www. Talsico.com )

11. HUMAN ERROR ANALYSIS TOOL ( HEAT )
HEAT Tool is a combination of
5 Whys
Method for getting people to think about true root cause
Prevents the investigation team from being satisfied with superficial solutions that won’t fix the problem in the long run
Gets to real Human Error Category
Recommended Actions V’s Talsico Human Error Category’s

15. Corrective Action :Error Control Hierarchy
Mistake-Proof (Poka-Yoke control)
– eliminate potential for errors – Engineering Controls
e.g Machine won’t start unless door is locked
Error Prevention (Poka-Yoke warning)
– SPC, alarms, dress code signs, yellow lines
e.g Alarm sound if car lights left
Error Detection
– Ability to “catch” error before accident or batch release
e.g Batch Record review, visual inspection
Redundancy
– Duplication of effort
e.g. multiple checks

16. The Data : 2009 Human Error Training Introduction of HEAT Tool
Year to Date
Human Error NOEs 24 %
Human Error Training
Introduction of HEAT Tool

17. Success & Next Step Next Steps Downward Trend
Human Error NOE’s down from 33 % to 24% of total NOEs
Inclusion
Employees engagement & satisfaction
Knowledge
Better understanding of Human Factors and error
Next Steps
Review effectiveness of CAPAs and quantify
Is the 5 Whys best tool or do we need a more diagnostic tool for drill down