NOE Human Error Reduction Schering Plough Brinny Donal
NOE Human Error Reduction: Schering Plough (Brinny ) Donal O’Callaghan & Julie Wade
Agenda ► Definition of Human Error ► Human Error Data from Brinny ► Types of Human Error ► Error Reduction Hierarchy ► The HEAT Tool ► The results to date…. . next steps 2
What are Human Errors ? “An inappropriate action or response by a person resulting in an undesired outcome” 3
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NOE Data 2008 33 % of NOEs Root Cause was Human Error 5
What did the data tell us? ► Human Error NOEs consistently accounted for 33% of total NOEs ► Training Common Response – Investigate & Train – Many errors not due to lack of skill or knowledge. ► Number of Human Errors were not reducing ► Similar issues re-occurred over and over again re- training is NOT working. ► Training can only solve a Human Error when the cause is lack of skill or knowledge 6
Human Error Factors Training 18 % ? ? ? 7
Human Error Factors Training Physical or mental capacity? Recognition Support? Clarity of expectations? Working conditions? 8 Clarity of instruction? Feedback
Brinny : Human Error Categories* on Trackwise § Learning Gap – don’t know or don’t understand – no training or poor quality training § Memory Gap – know, but don’t remember – after break, after holidays, long absence – after recent change not reinforced § Application – know, but did not use correctly – over burden - stressed (*Source Talsico ; www. Talsico. com ) 9
Brinny : Human Error Categories* on Trackwise § Attention know but distracted by other factors – wrong position – visual inspection units wrong place § Omission – know, but missed a step – overburden, pressure § Decision – incorrect decision is made – decisions are emotional why was wrong one made? § Procedure – inconsistent performance due to poorly documented procedure (*Source Talsico ; www. Talsico. com ) 10
HUMAN ERROR ANALYSIS TOOL ( HEAT ) HEAT Tool is a combination of 5 Whys – Method for getting people to think about true root cause – Prevents the investigation team from being satisfied with superficial solutions that won’t fix the problem in the long run – Gets to real Human Error Category Recommended Actions V’s Talsico Human Error Category’s 11
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Corrective Action : Error Control Hierarchy 1. Mistake-Proof (Poka-Yoke control) – eliminate potential for errors – Engineering Controls e. g Machine won’t start unless door is locked 2. Error Prevention (Poka-Yoke warning) – SPC, alarms, dress code signs, yellow lines e. g Alarm sound if car lights left 3. Error Detection – Ability to “catch” error before accident or batch release e. g Batch Record review, visual inspection 4. Redundancy – Duplication of effort e. g. multiple checks 15
The Data : 2009 Human Error Training Introduction of HEAT Tool Year to Date Human Error NOEs 24 % 16
Success & Next Step ► Downward Trend – Human Error NOE’s down from 33 % to 24% of total NOEs ► Inclusion – Employees engagement & satisfaction ► Knowledge – Better understanding of Human Factors and error Next Steps ► Review effectiveness of CAPAs and quantify ► Is the 5 Whys best tool or do we need a more diagnostic tool for drill down 17
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