Insights on Environmental Health & Safety (EHS), Operational Risk and Product Stewardship

Finding the Error in Their Ways: How Companies Can Mitigate Human Mistakes

March 9th, 2018
James Tehrani
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People get overly tired. People get distracted; they get stressed and make poor decisions. People multitask when they shouldn’t. People lack training at times.

Our brains and bodies are machines, but they are imperfect ones at that. Even the most thorough and careful person will become an “err apparent” eventually because “mistakes can happen to anyone” as Gen Xers, especially in the Chicago area, learned from the vintage cartoon series “Most Important Person.” The negative results of human errors in the workplace can also be compounded by what occurs in the limbic system of our brains. Experts refer to this as the “lizard brain” area of the mind, which is where feelings of fear and freezing up emerge under certain circumstances.

And any incident caused by a worker’s mistake that leads to an “Oopsie,” “Uh-oh,” “Oh no” or even a “holy smokes” can and should be considered an Operational Risk to the organization.

Human mistakes are inevitable.

Knowing that, companies must be proactive about mitigating the risk from those mistakes. Software, including mobile apps, allows workers to be able to track incidents and near-misses easier as part of an Integrated Risk Management system that can help eradicate errors.

Christine Bergey is the manager of audit programs and business support systems at chemical company Arkema Inc. She explained during Sphera’s recent webinar titled “Understanding Human Error and Behaviors” that between 70 and 96 percent of workplace mistakes can be attributed to human error. That’s a lot of errors, and, without a doubt, human error is a big problem for Environmental Health & Safety.

As Bergey stated during the webinar, what many companies do after incidents is examine simple root causes or simple corrective actions. “As we all know, there’s a definition of insanity, which is, ‘Doing things the same way and expecting a different result,’ which is what will happen if you keep making these assumptions in your incident investigations,” she said. “Humans have the same brain that they always have had, but our work environment and our everyday life has changed.”

Three Common Responses to Incidents

Typically, there are three common responses to incident investigations, Bergey said:

  1. 1) Training and retraining staff
  2. 2) Disciplining workers
  3. 3) Writing, rewriting or updating procedures

Yet, repeat incidents continue to happen. But why?

Simply put, it’s because people are … people. To that point, Bergey said companies might have to change their thought process to focus on predictions of behavior rather than reactions to it.

After all, human errors, believe it or not, can be predictable.

Error Eradication

“If you can consider human error when you’re looking at incidents or when you’re doing behavioral-based safety observations or when you’re thinking about” near-misses, Bergey said, “you can really prevent that incident or prevent recurrence of the incident because you could predict that the human error will occur.”

Driving and Brain

For example, some human errors can be attributed to “auto-sequencing,” Bergey said. To explain the idea, she referenced a task that you do every day like driving home from work. The route is essentially programmed into your brain, and if you’ve ever experienced a time when you were driving and you couldn’t quite recall how you got so far along in your journey, it’s because your brain was basically working on auto-pilot. But what if, before you leave work for the day, your spouse calls and asks you to pick up milk along the way? Once you’ve initiated your daily driving pattern, it can be challenging to deviate from it. It’s very possible you could forget you’re on the “milky way” and come home empty-handed.

How could the error have been avoided? Instead of traveling the same route, you could have switched things up and gone a different way or even bought the milk first. Changing the script helps keep the mind focused on the task at hand and helps prevent the error. In the working world, it could translate to switching up tasks so that auto-sequencing doesn’t kick in and lead to errors caused essentially from monotony.

You’ve heard the cliché about “your mind playing tricks on you,” right? That can happen from repetition. Say an experienced operator knows which valve to turn and when to turn it, Bergey said, but there’s that odd feeling that sometimes happens where doubt creeps in. “I’m sure I need to close this valve now, but …”

Decision time.

So what happens after the “but”? Does the worker go with a gut feeling and turn the valve or does the worker double-check the sequence first? To help eliminate mistakes, training workers to always double-check when they’re not sure—and empowering them to feel comfortable doing so—can help minimize mistakes.

Additionally, companies can help workers’ brains process information quicker by remembering that the brain likes to see numbers broken up into three or four digits. It’s a lot easier for the brain to process when a number is written as 314-1592-6535-8979-3238 than 3141592653589793238. So if a valve has a long number attached to it, Bergey said, by breaking up the number into groups of three or four like you would a telephone number, it will help with recognition. Also, the mind recognizes symbols quicker than words, so a picture of a safety glove, for example, will register quicker than a sign that says, “Wear your safety gloves in this area.”

“Some of the ways that we can reduce the errors are called ‘attention activators,’ ” Bergey said. “Attention activators are used to kind of interrupt that auto-sequence and point to something that’s important or allow the reader to understand the materials better so the brain looks at that and recognizes that information better.”

Healthy Doses

Another example Bergey offered was in the health care setting. One medical facility was seeing a big jump in the number of prescription mis-dosings, meaning either patients weren’t getting their medications or were getting the wrong medications. Administering the wrong prescription or administering an improper dosage of a medication could obviously make a patient sicker or even kill a person, which would open the hospital up to enormous legal exposure.

Nurse brain mistakes

The knee-jerk reaction from the health care facility was that it needed to retrain its nurses. Clearly the nurses needed a refresher course in their training from nursing school, right? Wrong; it didn’t help.

The next step was to review all dosing procedures. Again, nothing changed. Finally, the hospital decided it was time to discipline nurses who made dosing mistakes. Still, the mis-dosings continued. That’s because the root cause of the problem had not yet been exposed.

After an investigation, what the hospital found was that the mistakes were being made because of doctors interrupting nurses during dosing sessions, Bergey explained. Observers discovered that the distractions would lead to the mistakes because busy nurses would lose track of if they had already administered the proper dosage to the patient or sometimes even which patient should be getting the medication. To combat the problem, a system was put into place where an indicator would let doctors know that a patient was getting medication and that the nurse should not be interrupted. With that process in place, the number of mis-dosings decreased.

Eliminating human errors is a difficult challenge, but it can be done through a behavioral safety approach, she said.

“Human error is the starting point for analysis; it’s not the end,” Bergey said. “Once you determine what the human error was associated with the incident, then you need to determine how to counteract it.”

Make no mistake about that.

For more on this topic, you can watch the full webinar on demand.

James Tehrani

James Tehrani is Sphera’s content marketing manager. He is an award-winning writer and editor based in Chicago.

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