Human error- Ask me anything about Human Error

How do you manage human error at your sites?

Hi @Ginette,

What are the most common types of human errors you see in manufacturing processes?


There are various, but the most common are related to incomplete procedures (a particular situation not covered) because we do not use conditional statements as much as we should.

Another biggie is excessive documentation. I beleive that 30% of the things we document are not even necessary. Too many verifications and people lose respect of their signature, so errors move forward.

Also the myth of multitasking. I can do 2 things in the same period of time but I can’t do them concurrently. At this point I will have to share my resources of attention between tasks.

There are many more. I have a Root Cause Determination Tool that I tried to attach to this post but I am not allowed so you can email me and I’ll send it to you.

Hi Ginette,

As a new user you were at trust level 0 we have bumped you up to trust level 1 so now you can upload that attachment.

It will be very useful to our community.

GMC RCDT-2010.pdf (74.9 KB)

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sense of responsibility of a worker is also one of the key factor leading to human error. This is the most difficult part to tackle…when a worker is overload, running with time, have to solve a variety of problems, handling a lot of document, the level of responsibility may decrease, hw is he/she going to maintain the job performance under such condition in order to minimize the error? what can be done by the superior/management?

I think you will also find these three articles interesting…concerning behavioral based analysis in a GMP environment.

Thanks. Will review soon!

Hi! Thanks for your question.

I believe you are referring to consequences of cognitive overload and not necessarily sense (or lack of) of responsibility.
When a person is overloaded survival mode takes over our memory, attention and decision making resources. What we do in these cases is assess the level of cognitive load to evaluate if it is over the threshold. If that is the case we can do a few things: for example, we can evaluate the task at hand and incorporate barriers of defense into the process, increase time for activity, or simplify or complicate the activity (depending the application), among many other categories associated with cognitive overload. Also we highlight/emphasize CRITCAL steps, tasks and data in BR to make sure that workers have the information to select action towards the most important activities/documentation when resources of attention can be compromised. On the other hand, we can educate workers on self regulation and supervisors on calibration of behaviors (correct improper performance in a timely fashion). There are so many things that can be done! Let me know if you want more information in this topic.

Hi Ginette, thank you so much for the info. How do we determine the level of cognitive load? I do agree sometime when a problem happened, we will add additional step (the so called barrier of defense in order to fill the loop hole so that it is not repeated). However, eventually I realized that, the problem may be solved, but the procedures increase, where the people is still overload and overload with the so many documentation/procedure, and then another human error will be created