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Human Error Reduction

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Human Error Reduction

  1. 1. Extract Only Talsico International Presented by: Susan Lynn These materials remain the property of Talsico International and may not be reproduced or used in any form or for any purpose without the written permission of Talsico International. www.talsico.comHuman Error Reduction © 2011
  2. 2. Talsico [ Healthcare & Pharmas ü Systems & tools to reduce human errors ü Offices [ USA, Australia, Puerto Rico, South Africa ü Clients [ All 7 continents ü Work where cost of human error is high ü Pharmaceuticals [ 9 of Global top 10Human Error Reduction © 2011
  3. 3. What are Human Errors? “An inappropriate action or response by a person resulting in an undesired outcome”Human Error Reduction © 2011
  4. 4. Left Brain, Right Brain ExerciseÑHuman Error Reduction © 2011
  5. 5. Key Points Input Output q 70-96% errors…Check the hidden processing – common response: retrain/”punish”? q Minimize conflicts q Ensure input is in the most appropriate format to achieve desired outputHuman Error Reduction © 2011
  6. 6. Topics What are Human Errors? – Why “train or punish” doesn’t workError Control HierarchyCategories of Error & Strategies for Prevention Learning Gap Memory Gap Omission Case StudyHuman Error Reduction © 2011 ~
  7. 7. Human Error Reduction © 2011
  8. 8. Section 2 Memory Gap Errors (Extract Only)Human Error Reduction © 2011
  9. 9. Recognition vs RecallHuman Error Reduction © 2011
  10. 10. Recall….Exercise Typically < 10% of people can do this!Ü Human Error Reduction © 2011
  11. 11. Recognition….Exercise Typically 100% of people can do this!Human Error Reduction © 2011
  12. 12. Recognition vs Recall 2 1 Recognition easier to learn, Brain uses 2 different processes for less error-prone, more remembering! stable than recall. Recognition - “from a list, point out ..” Where possible, design for Has external starting point recognition rather than recall Recall – no external starting point Recognition vs Recall – learn to req’d level 3 4 Recognition – use Accessible? SOPs, aids, system Physical Accessibility = prompts, PPMs. Must “Within Reach” be accessible otherwise Cognitive Accessibility = forces “recall” Easy to “Grab” req’d infoHuman Error Reduction © 2011
  13. 13. Recognition – Accessibility! Process Picture MapsTMCognitive Accessibility? ü ü Cognitive Accessibility?Human Error Reduction © 2011
  14. 14. Auto-sequencesHuman Error Reduction © 2011
  15. 15. Habits & Auto-sequences Habits & Auto behavior– processed differentlyHuman Error Reduction © 2011
  16. 16. Auto-sequence Exercise How did it feel?Human Error Reduction © 2011
  17. 17. Section 5 Omission Errors (Extract Only)Human Error Reduction © 2011
  18. 18. Assignment – Learning Outcomes q Rank the following Attention Activators in order of effectiveness: shape, motion, sound, text, colorHuman Error Reduction © 2011
  19. 19. Attention Activation Attention Activation– Alertness, focus, goalµ Human Error Reduction © 2011 ~
  20. 20. Attention Activators (Types by strength) 1. Sound 2. Motion or change in pattern 3. Color 4 Shape . 5. TextHuman Error Reduction © 2011 ~
  21. 21. Observation & Suggestions Tools & case studyHuman Error Reduction © 2011
  22. 22. To Err . . . is AvoidableHuman Error Reduction © 2011
  23. 23. Human Error Reduction © 2011
  24. 24. HE Investigation & DiagnosticsInvestigate Determine ErrorüEstablish collaborative intent Diagnose Cause(s) &üStructured interview process Categories üFocus on relevant Explore RecommendedüFair, consistent, effective Actions area(s) Human Error Reduction © 2011
  25. 25. 1. Analyze “the job” _ Science of H.E.R Identify Human Error Reduction Opportunities (H.E.R.O) • Tasks, • Equipment, • Systems, • Workflow, • Physical environment, • Interactions – human to equipment • Interactions – human to human • Paperwork – forms filled • Paperwork – procedures & manuals Identified 30 opportunities. • Cognitive processes required, • Learning acquisition & assessment Many able to be • Culture implemented immediately • ….Human Error Reduction © 2011
  26. 26. 2. Redesign Forms, InsertsOriginal Lengthy & wordy (~43 Shorter & clearer (~25 New pgs, ñ text) pgs, textò74%) Important info “lost” Attention Activators among general body for important info! Error-prone! Paperwork errors ò65% Time-consuming to fill in & Saved ~1 hr per review review ($$) ($$$$$) Human Error Reduction © 2011
  27. 27. 3+. Redesign & Integrate Procedures, Instructions… Learning System…for hospital, caregiver, patientOriginal Procedure More effective New PPM ò66% shorter Error-prone! Long, hard to follow, not “useful”! 0 human errors for 18+ months! (previously ~ 2 ER / mth)Human Error Reduction © 2011
  28. 28. hank ou Talsico InternationalHuman Error Reduction © 2011

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