This document discusses human error in manufacturing processes and its causes. It states that most defects are due to human error rather than technological failures. While individuals are accountable for errors, the document argues that systems should be designed to minimize human mistakes since people want to do the right thing. Perfect systems require perfect humans, but human behavior is influenced by various factors like stress, fatigue, and limitations in attention, memory and situation awareness. Therefore, systems should be designed based on an understanding of human factors in order to reduce errors.
Human factors - what role should they play in Responsible CareAdvisian
This presentation examines one facet of Human Behaviour and how attention paid to it enhances the ability of users to achieve and sustain performance excellence in terms of Plant Reliability and Safety
4. ETHICS IN ENGINEERING (ETC) 3130004 GTUVATSAL PATEL
Scope of engineering ethics, Accepting and sharing responsibility, Responsible professionals and ethical corporations, Resolving ethical dilemmas, Making moral choices
Explaination of More Personal Safety program designed and delivered by Safety Culture Initiative for public use and filling gap of human resources risk management at nation state and company level.
First phase of MPS program is action "From Zero To Hero" delivered during Cybersecurity October to Poland and other countries in Polish and English language.
You are facing a lot of human errors in your organization and you want to improve the performance of your team. Use this new and systemic approach to define a successful action plan.
Human factors - what role should they play in Responsible CareAdvisian
This presentation examines one facet of Human Behaviour and how attention paid to it enhances the ability of users to achieve and sustain performance excellence in terms of Plant Reliability and Safety
4. ETHICS IN ENGINEERING (ETC) 3130004 GTUVATSAL PATEL
Scope of engineering ethics, Accepting and sharing responsibility, Responsible professionals and ethical corporations, Resolving ethical dilemmas, Making moral choices
Explaination of More Personal Safety program designed and delivered by Safety Culture Initiative for public use and filling gap of human resources risk management at nation state and company level.
First phase of MPS program is action "From Zero To Hero" delivered during Cybersecurity October to Poland and other countries in Polish and English language.
You are facing a lot of human errors in your organization and you want to improve the performance of your team. Use this new and systemic approach to define a successful action plan.
Engaging staff in Health and Safety, do rules work? - Golden rules thoughts 2...Gideon Bernto
Engaging employees in health and safety - do rules work?
Some useful insights on what works and what doesn't work as well..Large organisations which are seeking to harmonise HS&E management across their different processes and sites often look to – among other actions – deploy a set of rules – such as ‘Golden Safety Rules’. But do they work? Is this the right name for them? And how do you go about naming, defining, implementing and enforcing them? Is the ‘rules’ word a turn-off right from the beginning? Does making them ‘golden’ elevate them to the right spot?
Fundamentals of testing - Testing & Implementationsyogi syafrialdi
As we go through this section, watch for the Syllabus terms bug, defect, error, failure, fault, mistake, quality, risk, software, testing and exhaustive testing. You'll find these terms defined in the glossary.
This guide offers advice on business continuity planning that is suitable for business of this size. This includes tips and strategies you can implement in your working practices to make your business more secure.As this guide is focused on the North West and Manchester, it also includes local business and resources that can help with your business continuity planning.
This guide includes:
· Facts about business continuity
· The first steps towards creating a business continuity plan
· Effective business continuity strategies
· How to test your business continuity plan
· Useful resources
· North west based companies that can help
When people fail to follow rules and procedures they usually know what they should be doing. Although, there are some cases where people mistakenly violate rules because they failed to understand the rule or did not know it existed.
Meaning of work environment, Fatigue, Implications of fatigue, causes and symptoms of fatigue, monotony and boredom, factors contributing to monotony and boredom, Industrial accidents, Employee safety, Morale, Grievance and Grievances handling, Personnel records & Personnel Audits.
Hope this will help you reduce human error in your industry. The contents have been taken from several references. Some of them are mentioned in the slide.
Hybrid Workplace Harassment: Are You Protecting Your Company from Hidden Thre...Case IQ
In today’s “new world of work,” many organizations run on a hybrid model, with some employees working remotely and others in the physical office. While this set-up is convenient, it can cause unique interpersonal issues between employees.
Reduced face-to-face communication makes it harder for teams to bond, while making it easier for harassers to get away with bad behavior. To reduce harassment incidents in your hybrid workplace, you need to foster a culture of openness, willingness to learn, and compassion.
Join workplace investigation and executive management expert Kenneth McCarthy as he outlines how to address and prevent hybrid workplace harassment incidents.
Engaging staff in Health and Safety, do rules work? - Golden rules thoughts 2...Gideon Bernto
Engaging employees in health and safety - do rules work?
Some useful insights on what works and what doesn't work as well..Large organisations which are seeking to harmonise HS&E management across their different processes and sites often look to – among other actions – deploy a set of rules – such as ‘Golden Safety Rules’. But do they work? Is this the right name for them? And how do you go about naming, defining, implementing and enforcing them? Is the ‘rules’ word a turn-off right from the beginning? Does making them ‘golden’ elevate them to the right spot?
Fundamentals of testing - Testing & Implementationsyogi syafrialdi
As we go through this section, watch for the Syllabus terms bug, defect, error, failure, fault, mistake, quality, risk, software, testing and exhaustive testing. You'll find these terms defined in the glossary.
This guide offers advice on business continuity planning that is suitable for business of this size. This includes tips and strategies you can implement in your working practices to make your business more secure.As this guide is focused on the North West and Manchester, it also includes local business and resources that can help with your business continuity planning.
This guide includes:
· Facts about business continuity
· The first steps towards creating a business continuity plan
· Effective business continuity strategies
· How to test your business continuity plan
· Useful resources
· North west based companies that can help
When people fail to follow rules and procedures they usually know what they should be doing. Although, there are some cases where people mistakenly violate rules because they failed to understand the rule or did not know it existed.
Meaning of work environment, Fatigue, Implications of fatigue, causes and symptoms of fatigue, monotony and boredom, factors contributing to monotony and boredom, Industrial accidents, Employee safety, Morale, Grievance and Grievances handling, Personnel records & Personnel Audits.
Hope this will help you reduce human error in your industry. The contents have been taken from several references. Some of them are mentioned in the slide.
Hybrid Workplace Harassment: Are You Protecting Your Company from Hidden Thre...Case IQ
In today’s “new world of work,” many organizations run on a hybrid model, with some employees working remotely and others in the physical office. While this set-up is convenient, it can cause unique interpersonal issues between employees.
Reduced face-to-face communication makes it harder for teams to bond, while making it easier for harassers to get away with bad behavior. To reduce harassment incidents in your hybrid workplace, you need to foster a culture of openness, willingness to learn, and compassion.
Join workplace investigation and executive management expert Kenneth McCarthy as he outlines how to address and prevent hybrid workplace harassment incidents.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
2. What causes defects?
“ The great majority of reported defective medicinal
products has resulted from human error or
carelessness, not from failures in technology”
MHRA , Orange Guide 2002
Can this really be true?
If most defects are caused by non-compliance with
GMPs, and most non-compliances are caused by
human error or carelessness, then what causes
human errors or carelessness?
2
3. How Many Es?
FRED IS A PRODUCTION OPERATOR. FRED IS FEARFUL THAT
HE MIGHT ERR IN HIS FIELD OF WORK AND SUBSEQUENTLY
FEEL THE IRE OF QA FOR HIS FAILURE TO HIS DUTY OF CARE.
FRED WORKS FOR A DEPARTMENT THAT MUST CARRY THE
BURDEN FOR HIS ERROR. TODAY WE HOLD INDIVIDUALS
ACCOUNTABLE FOR THEIR ERRORS BECAUSE WE SHOULD
EXPECT NOTHING LESS THAN FLAWLESS PERFORMANCE
FROM A HIGHLY TRAINED AND EDUCATED OPERATOR.
3
4. Human Error
4
Human behaviour
explains human
error
• Therefore, looking
at why and how we
behave in certain
situations helps to
explain why we do
what we do.
Human error is
rarely random.
• It is connected to
the tools, tasks and
environment. That
is, it can often be
predicted, and in
some situations, is
inevitable.
People want to do
the right thing.
• We do what
makes sense to
us at the time
given our focus
of attention,
knowledge and
goals
Studies tell us that EVERYONE commits errors
5. Perfect Systems need Perfect Humans
• Systems and processes are not inherently compliant
• People must create compliance using tools, systems
and technology
• Therefore systems that depend on perfect
behaviour are inherently flawed
5
6. How Many Es?
FRED IS A PRODUCTION OPERATOR. FRED IS FEARFUL THAT HE
MIGHT ERR IN HIS FIELD OF WORK, AND SUBSEQUENTLY FEEL
THE IRE OF QA FOR HIS FAILURE TO HIS DUTY OF CARE. FRED
WORKS FOR A DEPARTMENT THAT MUST CARRY THE BURDEN
FOR HIS ERROR. TODAY WE HOLD INDIVIDUALS ACCOUNTABLE
FOR THEIR ERRORS BECAUSE WE SHOULD EXPECT NOTHING
LESS THAN FLAWLESS PERFORMANCE FROM A HIGHLY
TRAINED AND EDUCATED OPERATOR.
6
7. Human Factors
• Human factors engineering (HFE) is the science of
designing systems to fit human capabilities and
limitations - in perception, cognition, and physical
performance.
• Poka-Yoke is a device or method that prevents
people from making mistakes. The word in
Japanese means mistake proofing or error
proofing. (Originally the word Baka-Yoke or idiot
proofing was used!)
7
10. Human Factors
Example of human limitations …..
• Attention – may be limited in duration or focus, especially if
attention must be spread
• Memory – working memory is limited, especially when active
processing of information is required
• Situation awareness – refers to a person’s perception of
what’s happening around them
• Automaticity – consistent, over-learned responses may
become automatic and completed without conscious thought
10
11. Human Factors
• Stress - Occurs when there is a mismatch between
what people are expected to do or cope with and the
resources available to them
• Fatigue - Caused by too much or too little to do,
sustained activity, physical / emotional exertion,
amount / quality of sleep, time of day.
11
12. Source of errors
• Processes may be referred to as having sharp and
blunt ends.
Sharp end –the person actually doing the task
Blunt end – the influences on the process farther
away from the action itself. Management,
administration, process & equipment designers,
internal regulators
12
13. Another View on Errors / Problems ….
“…most troubles and most possibilities for improvement
add up to proportions something like this:
* - 94% belong to the system (the responsibility of
management)
* - 6% are attributable to special causes.
The New Economics” 1994 – Ch. 2 -The Heavy Losses-, page 33
Often quoted as "The system is responsible for 94% of
problems" or "Management is responsible for 94% of the
problems“
13
14. How do we respond to errors?
• Aviation and Nuclear industries way ahead
• “Name, blame and train” strategy
• We “fix” the person, should “fix” the system
• Find root cause and focus on this
• Implement a “just culture”
Dr Rollin Fairbanks M.D.
14
16. How might we hinder compliance?
• On 25th January 2000, Dr Lucian Leape (a Harvard professor of
health) told Congress that the single greatest impediment to
error prevention in the medical industry is that ‘we punish
people for making mistakes’
• We may be seen as punishing people for reporting their own
mistakes or those of others, driving practises underground
• May be removed from the action – not part of the team.
16
17. Errors versus choices (behaviour)
• Our physical and mental limitations as humans can
explain the unintentional errors we make. These
may result in a non-compliance or deviation, but
they are not deliberate
• What about the deliberate choices we make?
17
18. Punishing Non-Compliance
• Should people be punished for deliberate non-compliance?
Should they be held personally accountable?
• Must consider;
– Unintentional errors
– Risky behaviour
– Reckless behaviour
18
19. At-Risk Behaviour / Routine Violations
• At-risk behaviour is when the person believes the benefit of NOT
complying exceeds the benefit of complying. For example …….
– Following an expired procedure because it still works
– Filling in signatures after the work is done because too busy
– Not reading a document before signing it
• Becomes entrenched because there is no harm caused therefore no
blame. Or worse, it may be rewarded because it may help to meet other
goals
• There is a risk that certain kinds of (GMP) non-compliant behaviour
become the norm and therefore represents (organisational) compliant
behaviour.
19
20. Reckless Behaviour / Extraordinary Violations
• Reckless behaviour is when the risk associated with the
behaviour outweighs the benefits of the behaviour. For
example ………
– Ad hoc change to manufacturing parameters to speed up
the process
– Using a raw material from a different supplier
• Does not mean there is an intent to do harm
20
21. Console, Coach, Punish
• Console the human error
• Coach the at-risk behaviour
• Punish the reckless behaviour
………..regardless of the outcome
This is known as a ‘Just Culture’ – that is, a fair culture.
21
22. 22
Australia
SeerPharma Pty Ltd
ABN # 28096346173
Melbourne (Head Office)
Level 1, 38 – 40 Prospect St.,
Box Hill, Victoria, Australia 3128
Phone: + 61 3 9897 1990
Fax: + 61 3 9897 1984
Sydney
P.O. Box 74
Engadine NSW 2233
Singapore
SeerPharma (Singapore) Pte Ltd
RCB # 200402111D
10 Anson Road,
#20-05 International Plaza
Singapore 079903
Phone: + 65 6774 5800
Fax: + 65 6774 6800
www.seerpharma.com