One of my most frequently viewed posts is on human errors. I am intrigued by this. I’ve run training on root cause analysis a number of times and occasionally someone will question my claim that human error is not a root cause. Of course, it may be on the chain of cause-and-effect but why did the error occur? And you can be sure it’s not the first time the error has occurred – so why has it occurred on other occasions? What could be done to make the error less likely to occur? Using this line of questioning is how we can make process improvements and learn from things that go wrong rather than just blame someone for making a mistake and “re-training” them.
There is another approach to errors which I rather like. I was introduced to it by SAM Sather of Clinical Pathways. It comes from Gilbert’s Behavior Engineering Model and provides six categories that need to be in place to support the performance of an individual in a system:
| Category | Example questions |
| Expectations & Feedback | Is there a standard for the work? Is there regular feedback? |
| Tools, Resources | Is there enough time to perform well? Are the right tools in place? |
| Incentives & Disincentives | Are incentives contingent on good performance? |
| Knowledge & Skills | Is there a lack of knowledge or skill for the tasks? |
| Capacity & Readiness | Are people the right match for the tasks? |
| Motives & Preferences | Is there recognition of work well done? |
Let’s take an example I’ve used a number of times: getting documents into the TMF. As you consider Gilbert’s Behavior Engineering Model you might ask:
-
- Do those submitting documents know what the quality standard is?
- Do they have time to perform the task well? Does the system help them to get it right first time?
- Are there any incentives for performing well?
- Do they know how to submit documents accurately?
- Are they detail-oriented and likely to get it right?
- Does the team celebrate success?
I have seen systems with TMF where most of the answers to those questions is “no”. Is there any wonder that there are rejection rates of 15%, cycle times of many weeks and TMFs that are never truly “inspection ready”?
After all, “if you always do what you’ve always done, you will always get what you’ve always got”. Time to change approach? Let’s get beyond human error.
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Picture: Based on Gilbert’s Behavior Engineering Model