Transcript
Human Error Prevention
CLS Human Error Prevention
TheHumanErrorPrevention(HEP)processisaboutunderstandingthatHumanErrorisnevera true root cause for an issue. The basicassumptionisthatpeopledonotwanttomakemistakes. Thinking systemically, HEP allowsyou topeel backmore layers of theproblem,uncover the true root cause and implementpermanent�ixes.Thereare4maincategoriesofHumanError,eachwithitsownsubcategories(someofwhichareillultratedover-leaf).
HumanErrorCategories(theCODE)
Ÿ DevelopacultureofHumanErrorPrevention
Ÿ MinimiseRiskofHumanErrorŸ NearMissesandAccidentsreduced
Ÿ QualityDefectsreduced
Ÿ ImproveJobSatisfactionŸ ReduceCostofPoorQuality
Human Error Decoded
De�initions
HumanError:An or involvingAction Decision,a human, which results in an unintended orundesirableoutcome.
How Can CLS Help You?
Decoding Human Error
CompetenceErrorsoccurwhenapersondidnothavetheknowledgeorskilltoperformthetaskcorrectly.
Output
Procedures
Forms
Training
Work Design
Communication
Workplace Design
KPIs
HEP
Competence Omission
ExecutionDecision
Ÿ HEPforLeadershipŸ HumanErrorProblemSolvingProcessŸ HumanErrorRiskOverviewScore(HERO)Ÿ ToolboxforHumanErrorPreventionŸ VisualSOPTraining02
03
0401
Strategy Development
HERO Baseline
Manage the Change
Training
OmissionErrorsoccurwhenapersonmissedastepordidnotperformanaction.
Execution Errors occur when a task isperformedincorrectly,althoughthepersonwascompetenttocarryitout.
DecisionErrorsoccurwhenapersonmakesadecisionwhichinadvertentlyleadstoanerror.
Ÿ StrategyDevelopmentŸ ProgramMentoringŸ HEROWorkShopŸ HumanErrorRootCauseAnalysisFacilitation
Training
Consultancy
Step1:De�inetheStrategy
Ÿ De�inepurposeoftheHEPprogramŸ Plantoin�luencechangeŸ CommunicationPlanŸ SelectPilotProgram
Step2:TrainingonHEP
Ÿ IdentifyHEPtrainingRequirementsŸ LeadershipTrainingŸ HEProblemSolvingTraining(seeoverleaf)Ÿ HEToolsTraining
Step3:DevelopHEROScore
Ÿ IdentifyBaselineHumanErrorRiskOverview(HERO)score
Step4:ManagetheChange
Ÿ CreateanActionPlanŸ EstablishaRecognitionProcessŸ MonitortheChange
TheCLSHEPProgram
Bene�itsoftheHEPProcess
info@crystalleansolutions.ie
+353 (87) 6226899
Loughlinstown, Fedamore, Co. Limerick
www.crystalleansolutions.ieHEROBaseline:TheHumanErrorRiskOverviewscore(HERO)providesaprocessformeasuringoverallriskofHumanError.
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