Monday Mornings with Madison

Preventing Human Error

It’s been said many times that ‘to err is human, to forgive divine.’  Few would argue that at least the first part of that statement is absolutely true.  No one is perfect.  To be human is to make mistakes.  Isn’t that why they put erasers on pencils?  But when people make mistakes at work, those errors can hurt business.  In fact, Marketwire reported in 2008 that human errors among employees cost businesses in the US and UK more than $37 billion in lost productivity.  While the vast majority of mistakes at work are minor and do little real harm, some mistakes are serious enough to reduce sales, damage customer relations, hurt the bottom line or even cause sentinel events — unexpected occurrences involving death or serious physical or psychological injury.

Although it is normal for people to make mistakes, human error is never welcome at work.  Companies have a vested interest in minimizing mistakes.  But is that even possible?  While it isn’t possible for any company to completely eliminate all slips and mishaps by staff, there are things that businesses can do to help reduce the quantity and impact of errors in daily operations.  The first step is to understand the finer distinctions in the nature of human errors and what factors cause employees to make more mistakes and slips.  The second step is for companies to design protocols that help to minimize errors.  Make no mistake, it can be done.

Slips and Mistakes

Industrial engineers, psychologists and other scientists have done extensive research on the nature, causes, consequences and prevention of human error.  In 1990, James Reason analyzed human errors and determined that basically they fall into two categories:  mistakes and slips. The distinction between a mistake and a slip has to do with intention.

Mistakes are basically fundamental miscalculations in determining a course of action.  A mistake is an error in choosing an objective or specifying a method of achieving it.  For example, a person decides on a course of action at work.  If the course of action or method of accomplishing it is not appropriate, this is considered a mistake.  For example, the recent decision by Hewlett Packard’s leadership to purchase the troubled software company Autonomy is an example of a mistake.  The New York Times called the acquisition a ‘misstep’ but the $5 Billion write off on the $10 Billion dollar purchase is likely viewed by investors as a painful mistake.  Hewlett Packard made a fundamental miscalculation not so much in their course of action – the objective being to remain a technology leader by acquiring companies developing new technologies – but in their method of accomplishing it… namely, to buy a business whose products and business methods it did not fully understand.  Mistakes usually reflect a lack of judgment, experience or savvy.

A slip, on the other hand, is an error that happens in the process of carrying out a particular objective.  If on the path to achieving an object, the action taken is not what was intended, then that is considered a slip.  In other words, a slip occurs when a person errs in the process of achieving an otherwise sound objective.  These are often the kinds of errors that doctors, pilots or air traffic controllers make.  The objective is typically sensible and wise but the error happens during the execution.  The doctor may choose the right course of treatment – such as surgery — but commits an error before, during or after the surgery. According to Robert J Sternberg, a psychologist and psychometrician, slips are most likely to occur when:

  • a person deviates from a routine, and an automatic process inappropriately overrides an intentional, controlled process; or
  • an automatic process is interrupted – either as a result of external events or data — such as a phone ringing or focus being diverted — or as a result of internal events — such as highly distracting thoughts.

Contributing Factors To Human Error

The opportunity for human error increases significantly for businesses that are either disorganized or lack proper resources.  Factors that contribute to human error include:

1. Poor applicant selection
Errors increase if a company is unable to hire the best candidates because there aren’t enough qualified applicants for high-skill positions or the compensation does not attract the best and brightest

2. Insufficient or inadequate training
Employees that do not have enough knowledge and understanding of their work are more likely to make mistakes and slips.  A fundamental lack of information increases the chances of failures in judgment and implementation.

3. Unqualified or inexperienced staff
Employees who lack the knowledge and training to perform efficiently are more likely to make mistakes or slips.

4. Stress
High levels of stress impact efficiency and effectiveness in the workplace. High-pressure jobs and stressful working conditions can cause distraction, indecision and confusion, which in turn increase the propensity for mistakes or slips.

5. Memory overload
Studies by the University of Illinois Human Factors Division (UIHFD) show that individuals have limited working memory, defined as the part of human memory that processes the microanalysis of a task and retrieves information from long-term memory. When a person’s working memory becomes overloaded, performance declines. Placing responsibility of too many intricate tasks on a single employee is an invitation for increased human error.

6. Work overload
Errors increase and productivity decreases when employees work excessive overtime, split-shifts and work nighttime schedules. Humans have built-in biological rhythms and patterns that generally create a natural waking and sleeping schedule. Working against natural patterns can increase fatigue, which leads to performance failures.

7. Forgetfulness / lack of communication
After a period of time of not reviewing certain policies or practices, employees are apt to forget a particular aspect or step in a process, especially if it is a task or process that isn’t performed regularly. Failure of management to periodically review processes with staff increases the likelihood of staff forgetfulness. Like errors, forgetfulness is another part of being human.

8. Overconfidence
Failure to periodically go over safety and operational procedures increases the likelihood of slips.

Protocols to Minimize Human Error

Nowhere is the need to reduce human error greater than in such fields as medical care, aviation, or the military.  It pays to takes some pages off their playbooks for reducing human error.  According to Robert Latino in a Briefing on Patient Safety for the medical community, the PDC Model stands for prevention, detection of precursors to errors, and correction of the causes of errors.

1.  Prevention is viewed as the most desirable strategy in reducing the risk of human error in the workplace.  Prevention strategies include:

  • Establishing a mission, goals, and priorities
  • Training workers, supervisors, and managers about comprehensive error avoidance/prevention techniques.
  • Creating an accountability system to hold everyone responsible for error-rate reduction

2.  Detection is about assessing the company’s current state and determining where there are opportunities for improvement where human error is concerned. This is still considered a proactive strategy because the goal is to identify areas at elevated risk for human error before the risk materializes.  Detection strategy includes:

  • Conducting periodic error analyses/assessments to identify event “drivers” existing in the organization.
  • Utilizing “leading,” “real-time,” and “lagging” performance indicators.
  • Optimizing surveillance and oversight programs.

3.  Correction is the last resort. At this stage, human error has occurred and actions are reactive.  Here, the goal is damage control and investigate to glean lessons learned from the event.  Correction strategy includes:

  • Implementing a technology/knowledge-based root cause analysis program for significant events
  • Providing human error training for management

While it is impossible to eliminate all human error, the goal of most any business should be to put strategies in place that will reduce costly human errors as much as possible.

Quote of the Week

“Success does not consist in never making mistakes but in never making the same one a second time.” George Bernard Shaw


© 2012, Written by Keren Peters-Atkinson, CMO, Madison Commercial Real Estate Services. All rights reserved.

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