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human error reduction PDA Pacific northwest
- 1. HUMAN ERROR REDUCTION Introductory Seminar October24, 2019 PDA Pac ific N orthwest Ch apter Presented by V irg in ia A n d reotti -Jon es
- 2. 2 ACKNOWLEDGEMENTS PDA PNW Chapter LisaRutter Alicia Sharkey Tony Yang Thank You for Your Support
- 3. 3 OBJECTIVES Learn foundations ofHuman Error Reduction Take away tool(s) you can use tomorrow Give you a place to start
- 4. 4 Human Error Reduction HumanError Prevention Human Factors Human Performance Human Error Management Human Engineering
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- 6. 6 HER Culture Understand WhyPeople Make Mistakes FOUNDATIONS OF HUMAN ERROR REDUCTION
- 7. HER CULTURE 7 Accept AllMake Mistakes Assume Positive Intent Blame Free Open Communication Focus on System Approach
- 8. HER Language “Is theSOP 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” 8 START WITH LANGUAGE
- 9. 9 Brains are Builtfor Survival Strongest Habit Prevails External Stressors WHY DO PEOPLE MAKE MISTAKES?
- 10. Motivation Habit Ability CHANGE BEHAVIOR Educate vsTrain Build New, Stronger Habits B=M+A+H 10 Behavior Change
- 11. ERROR PROOFING Eliminate Opportunities EngineeringControls ERROR PREVENTION Attention Activators Check Points 11 ELIMINATE MISTAKE OPPORTUNITIES
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- 14. 14 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
- 15. BRIEF CASE STUDY ProductFiltration 15
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- 17. 17 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
- 18. BRIEF CASE STUDY Operatorover-laid wrong compressed gas 18
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- 20. 20 Human Error ReductionTeam Value Stories SOP Writing Leader Coaching Trending & Analysis Employee Suggestions MORE HER TOOLS
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- 22. Resources BioPhorum (BPOG) NSF International ASQ PDA KeyWord Search “Human Error Reduction” “Human Performance” "Human Factors” “Error Proofing” “Mistake Proofing” “Error Reduction” 22 WHERE TO START
- 23. CONCLUSION Build an HERCulture Focus on System Approach Start Simple Start Tomorrow Reach Out 23
- 24. THANK YOU! A ny Final Questions? 24