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For many years, we considered human errors or mistakes as the cause of mishaps or problems. In the manufacturing industries, human error, under whatever label (procedures not followed, lack of attention, or simply error), was the conclusion of any quality problem investigation. The way we look at the human side of problems has evolved during the past few decades. Now we see human errors as the symptoms of deeper causes. In other words, human errors are consequences, not causes. The basic objective of this book is to provide readers with useful information on theories, methods, and specific techniques that can be applied to control human failure. It is a book of ideas, concepts, and examples from the manufacturing sector. It presents a comprehensive overview of the subject, focusing on the practical application of the subject, specifically on the human side of quality and manufacturing errors. In other words, the primary focus of this book is human failure, including its identification, its causes, and how it can be reasonably controlled or prevented in the manufacturing industry setting. In addition to including a detailed discussion of human error (the inadvertent or involuntary component of human failure), a chapter is devoted to analysis and discussion related to voluntary (intentional) noncompliance. Written in a direct style, using simple “industry” language with abundant applied examples and practical references, this book’s insights on human failure reduction will improve individual, organizational, and social well-being.
For many years, we considered human errors or mistakes as the cause of mishaps or problems. In the manufacturing industries, human error, under whatever label (procedures not followed, lack of attention, or simply error), was the conclusion of any quality problem investigation. The way we look at the human side of problems has evolved during the past few decades. Now we see human errors as the symptoms of deeper causes. In other words, human errors are consequences, not causes. The basic objective of this book is to provide readers with useful information on theories, methods, and specific techniques that can be applied to control human failure. It is a book of ideas, concepts, and examples from the manufacturing sector. It presents a comprehensive overview of the subject, focusing on the practical application of the subject, specifically on the human side of quality and manufacturing errors. In other words, the primary focus of this book is human failure, including its identification, its causes, and how it can be reasonably controlled or prevented in the manufacturing industry setting. In addition to including a detailed discussion of human error (the inadvertent or involuntary component of human failure), a chapter is devoted to analysis and discussion related to voluntary (intentional) noncompliance. Written in a direct style, using simple industry language with abundant applied examples and practical references, this book's insights on human failure reduction will improve individual, organizational, and social well-being.
For many years, we considered human errors or mistakes as the cause of mishaps or problems. In the manufacturing industries, human error, under whatever label (procedures not followed, lack of attention, or simply error), was the conclusion of any quality problem investigation. The way we look at the human side of problems has evolved during the past few decades. Now we see human errors as the symptoms of deeper causes. In other words, human errors are consequences, not causes. The basic objective of this book is to provide readers with useful information on theories, methods, and specific techniques that can be applied to control human failure. It is a book of ideas, concepts, and examples from the manufacturing sector. It presents a comprehensive overview of the subject, focusing on the practical application of the subject, specifically on the human side of quality and manufacturing errors. In other words, the primary focus of this book is human failure, including its identification, its causes, and how it can be reasonably controlled or prevented in the manufacturing industry setting. In addition to including a detailed discussion of human error (the inadvertent or involuntary component of human failure), a chapter is devoted to analysis and discussion related to voluntary (intentional) noncompliance. Written in a direct style, using simple industry language with abundant applied examples and practical references, this book's insights on human failure reduction will improve individual, organizational, and social well-being.
This book is a simulation of a live course on human performance improvement/human error prevention (HPI/HEP) created by the preeminent authority on HPI/HEP. It presents the greatest breadth of scope and specificity on this topic. This book comprises a focused, challenging human error prevention training course designed to improve understanding of error causation. It will dramatically reduce human error and repeat deviations, and it digs below the surface of issues and looks to fix the real causes of human error and mistakes. In addition, this book presents a complete seminar from the thought leader acclaimed by hundreds of clients, and includes unique principles, practices, models, and templates. Information is comprehensive and can be directly implemented. The principles and practices of human error prevention are universally applicable regardless of the type of industrial, commercial, or governmental enterprise, and regardless of the type of function performed within the enterprise. The application of the information in this book will significantly contribute to improved productivity, safety, and quality. After fully using this book, you will understand: Human error prevention/reduction terminology and definitions. The relationships among culture, beliefs, values, attitudes, behavior, results, and performance. The roles of leadership in establishing and maintaining a quality/safety-conscious work environment. The one fundamental precept explaining the importance of human error prevention/reduction. The two most critical elements of human error prevention/reduction. The three levels of barriers to human error. The four types of things in which the barriers may exist at each barrier level. The five stages of human error. The six "M"s that can emit or receive hazards activated by human error. The seven universally applicable human error causal factors. The Rule of 8 by which to prevent human error and mitigate its effects. Techniques for making barriers effective and the spectrum of barrier effectiveness. The relationship of human error prevention/reduction to the total quality/safety function. Error-inducing conditions (error traps) and behaviors for counteracting these conditions. Non-conservative and conservative thought processes and behaviors in decision-making. Coaching for preventing the recurrence of human error. Root cause analysis techniques for identifying human error causal factors. The nine types of corrective action. Human error measurement. Strategies for a human error prevention/reduction initiative. How to design, implement, and manage a human error prevention/reduction initiative.
Almost all the major accident investigations--Texas City, Piper Alpha, the Phillips 66 explosion, Feyzin, Mexico City--show human error as the principal cause, either in design, operations, maintenance, or the management of safety. This book provides practical advice that can substantially reduce human error at all levels. In eight chapters--packed with case studies and examples of simple and advanced techniques for new and existing systems--the book challenges the assumption that human error is "unavoidable." Instead, it suggests a systems perspective. This view sees error as a consequence of a mismatch between human capabilities and demands and inappropriate organizational culture. This makes error a manageable factor and, therefore, avoidable.
Human error is regularly viewed as an inevitable part of everyday life. In many cases the results of human error are harmless and correctable, but in cases where injury and death can occur, reduction of error is imperative. An integration of useful how-to-do-it information, Human Error: Causes and Control covers theories, methods, and specif
This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to: * inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care; * inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting; * cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload. The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care. Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine. The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.
This volume examines the nature of human error -- its causes and origins, its classifications, and the extent to which it is possible to predict and prevent errors and their impact. One of the first texts to deal with this topic in detail, it draws into a single cohesive account contributions from experts in a range of disciplines including psychology, philosophy, and engineering. Offering an insightful discussion of fundamental and necessary questions about the nature and source of human error, the book draws significant conclusions and identifies areas worthy of further exploration. This volume will be of interest to all who are concerned with the impact human error has on both the individual and society.
Risk management principles are effectively utilized in many areas of business and government, including finance, insurance, occupational safety, and public health, and by agencies regulating these industries. The U.S. Food and Drug Administration (FDA) and its worldwide counterparts are responsible for protecting public health by ensuring the safety and effectiveness of the drugs and medical devices. Regulators must decide whether the benefits of a specific product for patients and users outweigh its risk, while recognizing that “absolute safety” (or zero risk) is not achievable. Every product and every process has an associated risk. Although there are some examples of the use of quality risk management in the FDA-regulated industry today, they are limited and do not represent the full contribution that risk management has to offer. The present FDA focus on risk-based determination is requiring that the regulated industries improve dramatically their understanding and capability of hazard control concepts. In addition, the importance of quality systems has been recognized in the life sciences industry, and it is becoming evident that quality risk management is a valuable component of an effective quality system. The purpose of this book is to offer a systematic and very comprehensive approach to quality risk management. It will assist medical and food product manufacturers with the integration of a risk management system or risk management principles and activities into their existing quality management system by providing practical explanations and examples. The appropriate use of quality risk management can facilitate compliance with regulatory requirements such as good manufacturing practices or good laboratory practices. The content of this book will provide FDA-regulated manufacturers with a framework within which experience, insight, and judgment are applied systematically to manage the risks associated with their products. Manufacturers in other industries may use it as an informative guidance in developing and maintaining a risk management system and process. The two appendices add even more insight: Appendix A contains general examples of risk management, while Appendix B includes 10 case studies illustrating real examples of the quality risk management process across the medical product arena.
A comprehensive publication providing practical guidelines to develop a sustainable safety culture for student and practising aviation personnel; addresses and provides tools for error reduction and recovery, return on investment for risk management programs. This book serves as a practical guide as well as an academic textbook - a 'must have' for anyone involved in aviation maintenance.