HUMAN ERROR REDUCTION

Introductory S e m i n a r

O c t o b e r 2 4 , 2 0 1 9

P D A P a c i f i c N o r t h w e s t C h a p t e r

P r e s e n t e d b y V i r g i n i a A n d r e o t t i - J o n e s

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ACKNOWLEDGEMENTS

PDA PNW Chapter

Lisa Rutter

Alicia Sharkey

Tony Yang

Thank You for Your Support

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OBJECTIVES

Learn foundations of Human Error Reduction

Take away tool(s) you can use tomorrow

Give you a place to start

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Human Error Reduction

Human Error Prevention

Human Factors

Human Performance Human Error Management

Human Engineering

FOUNDATION

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HER Culture

Understand Why People Make Mistakes

FOUNDATIONS OF HUMAN ERROR REDUCTION

HER CULTURE

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Accept All Make Mistakes

Assume Positive Intent

Blame Free

Open Communication

Focus on System Approach

HER Language

“Is the SOP clear, concise, and easy

to follow”

“Change the process to prevent…”

“What tools can we implement to

fix…”

Blaming Language

“They should have seen that”

“You need to focus more”

“Add another review step to

catch that”

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START WITH LANGUAGE

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Brains are Built for Survival

Strongest Habit Prevails

External Stressors

WHY DO PEOPLE MAKE MISTAKES?

Motivation

HabitAbility

CHANGE BEHAVIOR

Educate vs Train

Build New, Stronger Habits

B=M+A+H

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Behavior Change

ERROR PROOFING

Eliminate Opportunities

Engineering Controls

ERROR PREVENTION

Attention Activators

Check Points

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ELIMINATE MISTAKE OPPORTUNITIES

TWO SIMPLE TOOLS

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PRE JOB BRIEFING

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Discuss:

• Task

• Documentation

• Roles, Responsibilities

• Critical Steps

• Potential Errors and Mitigation

• Operator Tips

• Trouble Shooting

• Stop Work Point

Extremely adaptable

Focus & prepare before task

Led by Front Line Personnel

Supervisors Support

Brief (10-15 min)

PRE JOB BRIEFING

BRIEF CASE STUDY

Product Filtration

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ROOT CAUSE DECISION TREE

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Assess Systems:

• Materials

• Machine

• Maintenance

• Measurement

• Environment

• Method

• Training

Use if "manpower" RC is identified

Ensures systems are assessed

Eliminate other causes

Leads to Meaningful CAPA

ROOT CAUSE DECISION TREE

BRIEF CASE STUDY

Operator over-laid wrong

compressed gas

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MORE COMPLEX

TOOLS

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Human Error Reduction Team

Value Stories

SOP Writing

Leader Coaching

Trending & Analysis

Employee Suggestions

MORE HER TOOLS

GETTING STARTED

Resources

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Resources

BioPhorum (BPOG)

NSF International

ASQ

PDA

Key Word Search

“Human Error Reduction”

“Human Performance”

"Human Factors”

“Error Proofing”

“Mistake Proofing”

“Error Reduction”

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WHERE TO START

CONCLUSION

Build an HER Culture

Focus on System Approach

Start Simple

Start Tomorrow

Reach Out

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THANK YOU!

A n y F ina l Quest ions?

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