Tools to Prevent Human Error

1. HOWE SCHOOL ALLIANCE FOR TECHNOLOGY MANAGEMENT ROUNDTABLE 28 February 2012 Steven Jacobs, MBA, R.Ph. President, Global BioPharm Solutions President, High Performing Teams, Inc. Tools to Prevent Human Error

2. Welcome • Roundtable Goals • Understand human error • Explore how the human brain contributes to human error • Utilize tools that prevent errors in the workplace

3. Logistics

4. References • New Research Leads to More Effective Ways of Reducing Human Error in the Workplace (2006). SBWire. Available online at: http://www.sbwire.com/press-releases/sbwire-5110.htm • Human Error: Causes and Control (2006). George A. Peters, Barbara J. Peters. CRC Press • Cognitive Systems Engineering (1994). Jens Rasmussen, Annelise Mark Pejtersen, L. P. Goodstein. Wiley publishing company

5. Facilitator Introduction • Introduction • Name • Background

6. Module 1: • Exploring Human Error

7. Apollo • Fire occurred when the spacecraft cabin was charged with pure oxygen • Electrical short under the seat of one of the astronauts, and oxygen fed the resulting fire • Men could not escape because of a poorly designed escape hatch • It is well known that pure oxygen atmospheres are very dangerous and that escape hatches must be simple to use and open quickly

8. Challenger

9. Challenger • Cold temperatures affected the performance of a seal already stressed due to an inadequate design • Previous Challenger inspections had shown that the seals were not holding up as intended during launches, and it was known that low temperatures would degrade them further.

10. Fukushima Nuclear Power Plant - Cause • Suffered major damage from a 9.0 earthquake and subsequent tsunami on 11 March 2011 • Reactors shut down automatically after the earthquake, and remaining decay heat of the fuel was being cooled with power from emergency generators • 14-meter tsunami waves disabled emergency generators required to cool the reactors (Reactors designed to handle 6-meter waves)

11. Fukushima Nuclear Power Plant - Impact • 1) Unit 1: Explosion, roof blown off • 2) Unit 2: Explosion, contaminated water in underground trench, possible leak from suppression chamber • 3) Unit 3: Explosion, most of concrete building destroyed, plutonium leak • 4) Unit 4: Fire, water level in spent fuel pools partly restored • 5) Multiple trenches: probable source of contaminated water, partly underground, leaked stopped

12. McNeil-PPC Product Recall History • McNeil first received complaints of an unusual moldy, musty, or mildew-like odor in its products leading to nausea, stomach pain, vomiting or diarrhea in early 2008 • Cause was chemical called "2,4,6-tribromoanisole (TBA)" which is applied to wooden pallets used for transport • Products contained small traces of TBA; pallets were traced to a plant in Puerto Rico

13. McNeil-PPC Product Recall Impact • Recognized as problem Sep-08 • First recall and FDA action Nov-09 • Recall widely expanded Dec-09 • Lack of action/prevention led to FDA taking over three J&J plants • Las Piedras, Puerto Rico • Fort Washington, PA • Lancaster, PA • Cost estimates are in the $50-$100 million range on top of $900 million in lost sales for 2010

14. Roundtable Activity 1 Instructions • Work in small groups • You have three (3) minutes • Use a piece of paper to capture your group’s work • Decide why each situation was an accident or human error • Designate a spokesperson to report out group’s decisions

15. Roundtable Activity 1 Debrief • Key words? • Define error and accident • Real-world examples?

16. Human Error • An inappropriate action or response, by a person, • resulting in an undesired outcome

17. Question • Which is preferred: error reduction or error prevention? Why?

18. Behaviors at Work • 1 Recall • 10 Discards • 30 Major Events • 600 Deviation Alerts • 3,000 Near Misses • 300,000 At-risk Behaviors

19. The Swiss Cheese Effect Organization • How can we improve work design, communication, roles and responsibilities, and tasks? Processes • How can we make processes more lean, robust, and reliable? Behaviors • How can we coach people so they develop the proper mindset and behaviors in response to conditions leading to errors? Processes Behaviors Organization Triggers Accidents James Reason (2002) Human Error, Cambridge Press

20. Question • Why do human errors occur?

21. Lego Activity

22. Roundtable Activity 2 Instructions • You have 10 minutes for this activity • Using only the set of instructions provided, assemble the LEGO object without errors

23. Roundtable Activity 2 Debrief • Which groups finished faster with no errors? • What errors did you encounter? • What, if any, steps needed to be redone? • What assumptions led to errors? • What could have been done to speed up the process while also preventing those errors?

24. Module 2: • The Brain’s Role in Human Error

25. The Brain • For 60,000 years, designed to: • Recognize and fight DANGER • Survive • Ensure basic needs met

26. Brain Stem, Cerebellum & Limbic System • “The reptilian brain” • Controls all vital functions • Sensory data for threats transmitted to here • Emotions rule here • Takes control when threat impairs safety • Takes control of movements and sequences when attention focus is required elsewhere • Cannot process complex sequences or information • Aborts any delegated tasks that cannot be done

27. Roundtable Activity 3 Instructions • You have five(5) minutes for this activity • Identify key opportunities in your work area where errors related to the cerebellum might occur

28. Temporal Lobe • “The Connector” • Hearing • Long term memory retention • Speech (the language zone) • Decides where to focus attention based on emotion • Expression Interpreter • Prioritizes people and social relationships

29. Roundtable Activity 4 Instructions • You have five(5) minutes for this activity • Identify key opportunities in your work area where errors related to the Temporal Lobe might occur

30. Frontal Lobe (Focus Brain) • “Executive center” • Controls your behaviors • Home to Personality • Higher cognitive functions occur here • Complex chains of motor movements are controlled here • Area responsible for switch tasking as multitasking is not possible

31. An Example of the Brain in Action… • Mr. X is driving down a secondary road, Hobart St., at 9:00 PM in an unfamiliar part of town. • He is late because he promised to pick up his wife at 8:45. • Mr. X is listening to the hockey game on the car radio, texting his wife, and looking for Front St., where his wife said to turn in order to reach his destination. • Ms. Y, wearing a dark blue coat and white hat, crosses in the middle of Hobart St without looking. Mr. X does not see her and strikes Ms. Y with his car. • Police arrive and question Mr. X, who says that he never saw the pedestrian. • What caused the accident?

32. Is Multitasking Possible? • See for your self…

33. Roundtable Activity 5 Instructions • You have five(5) minutes for this activity • Identify key opportunities in your work area where errors related to the Frontal Lobe might occur

34. Occipital Lobe • Short term memory center • Visual center of brain • Receives and interprets images • Rearranges information with existing information • Discards information • Works in conjunction with other lobes to process images into meaningful information • Differentiates color and shape

35. How can the occipital lobe be fooled: How many letter F’s? Finished files are the result of years of scientific study combined with the experience of years.

36. Continued: Read Out Loud I love Paris in the the spring time

37. Roundtable Activity 6 Instructions • You have five(5) minutes for this activity • Identify key opportunities in your work area where errors related to the Occipital Lobe might occur

38. Break time • You have 10 minutes

39. Root Causes of Errors • Memory Gap • Attention Gap • Learning Gap • Decision Gap • Procedure Gap • Resource Gap

40. Attention Gap • How the work environment affects the mind • Why Errors Occur: • Loss of focus • Reduced alertness • Absence of triggers

41. Roundtable Activity 7 Instructions • You have five(5) minutes for this activity • Work together as a group and identify no less than three(3) strategies that could prevent Attention Gap errors

42. Attention Gap Prevention Strategies • Chunk tasks • Rotate tasks • Change task schedule • Segregate similar task(s) • Isolate the activity • Minimize distractions • Reduce cognitive load

43. Cognitive/Mental LoadWhat error traps do you see?

44. Memory Gap • How the information is used in the course of action • Why Errors Occur: • Exceptions • Insufficient time to incorporate change(s) • Stronger rules dominate • Rigid (“Just do it!”) or contradictory Information

45. Roundtable Activity 8 Instructions • You have five(5) minutes for this activity • Work together as a group and identify no less than three(3) strategies that could prevent Memory Gap errors

46. Memory Gap Prevention Strategies • Color triggers • Bright triggers • Auditory triggers • Checklists • Job-aid/procedure • Process picture maps • Poka-yoke • Refresher training

47. Relying on MemoryWhat error traps do you see?

48. Mental FitWhat error traps do you see?

49. Learning Gap • Knowing what to do and how to do it • Why Errors Occur: • Ineffective training methodology • Lack of learning outcome verification • Failure to apply coaching

50. Roundtable Activity 9 Instructions • You have five(5) minutes for this activity • Work together as a group and identify no less than three(3) strategies that could prevent Learning Gap errors