To err is human, so John Kleeman reveals how to do it less often!
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Humans are capable of incredible feats, but we are also prone to random errors on occasion. From lapses in attention to misunderstanding a process, everyone is intimately familiar with the experience of making mistakes.
Something far fewer people consider is the perspective of organisations, which face the constant potential for mistakes from their employees and must attempt to prevent errors using a combination of training and procedure.
The term ‘human error’ refers to the idiosyncratic mistakes that people make. Whereas machines and computers typically fail in predictable ways, and the root cause of the failure is easy to determine and remedy, human employees are far more complex.
Errors made by people can be caused by anything from a slip of the hand, wandering concentration, misremembered training, or any number of countless other causes.
It is impossible to eliminate human error – after all, ‘to err is human’ – but there are steps that can be taken to reduce it.
The industries which think about human error the most are those which stand to be most impacted by a single error: aviation, medicine and finance, among others.
Human error can have a disastrous – and potentially fatal – impact in the healthcare industry. One major step toward preventing future errors is to understand and analyse previous ones.
Britain’s Medical and Healthcare Products Regulatory Agency (MHRA) collects statistics on the root causes of errors.
One major step toward preventing future errors is to understand and analyse previous ones
The agency logged 788 instances of human error across the UK in 2011 relating to blood transfusions and handling.
The MHRA conducted a root cause analysis to break this collection of errors into basic categories. A plurality of errors, 29% of them, were attributed to insufficient concentration.
Missing crucial steps and using incorrect processes were the second and third most common causes, with 23% and 22% respectively.
Other causes of error included insufficient or misunderstood training and poor communication, and these made up the rest of the cases.
Looking at the research, we can see that failure to adhere to proper procedure is a major source of errors, making up 45% of total errors.
In many industries, improper procedure can have fatal consequences. Consider aviation, where mistakes could be made at 35,000 feet.
Nervous fliers will be pleased to hear that this industry is among the most stringent in attempting to prevent procedural errors.
From aircraft servicing, where every screw is catalogued and tracked, to pre-flight checklists and emergency procedures, every procedure is focused on the safe operation of the complex vehicle.
In attempting to reduce human errors due to improper procedure, observational assessments offer a solution. These involve an expert assessing the ability of the test-taker to perform a particular skill.
It’s for this reason that aspiring pilots earn their licences by demonstrating that they can safely operate a plane as their instructor observes.
A lack of training, or misremembering and misunderstanding adequate training, collectively made up 21% of errors.
Training being a source of error also comes up in other analyses: for example, the FDA in the US conducted a study into manufacturing process errors and found that defective training contributed to 24% of such errors.
One solution to training errors is for organisations to focus on delivering assessments that are valid, reliable and fair.
Proper assessments pose questions that attempt to gauge an employee’s understanding, rather than simply measuring their ability to recall information.
Scenario-based questions are also useful for ensuring that employees are prepared for their job.
In addition to measuring employees’ understanding, assessments can also measure the efficacy of the training itself. If all of the employees are failing, or large numbers fall victim to the forgetting curve, the training may need to be revised to make it more engaging.
Some other training errors occur because the training doesn’t accurately reflect the requirements of the job.
In these instances, job task analysis – the practice of surveying practitioners to attempt to create an accurate image of the requirements of the role – can offer a solution.
What about the other categories of errors, such as focus? Solutions to these errors may need to be more systemic, perhaps including longer breaks or greater division of labour.
Fortunately, many industries have robust error analysis organisations, such as America’s National Transportation Safety Board (NTSB), which tracks down the causes of plane crashes and works tirelessly to prevent similar accidents in the future.
Warren Buffett famously observed that “it takes 20 years to build a reputation and five minutes to ruin it”.
However, companies are not helpless against human error. Strong organisational structures can prevent an individual mistake from propagating at scale, and initiatives like regular learning and development and regular assessments can make sure that everyone knows what they are supposed to do – and how to do it safely.
About the author
John Kleeman is executive director and founder of Questionmark