Issue link: https://www.e-digitaleditions.com/i/341135
W 24 July 2014 Tablets & Capsules quality The human factor: Finding the behavioral pre-conditions for error Ben Locwin Healthcare Science Advisors Never assume that the underlying cause of error is appropriately labeled "human" or "operator." Instead, look at the design of your systems and processes. This article provides examples of good and bad design and summarizes how to track quality using charts and graphs. Don't pick a red bead Consider Deming's well-known red-bead experiment. In this thought exercise, a bin contains 80 percent white beads and 20 percent red beads. The white beads represent a job well done, and the red beads represent defects or errors. Participants are asked to scoop out some beads and submit them for appraisal to the person designated as the manager. Clearly, each scoop of beads will likely contain "errors," and that's the point of the experiment: The number of errors each worker "commits" is beyond his/her control. It's built into the system and does not measure actual performance. In this example, no matter how hard you work, with every scoop of say, 25 beads, you can expect about five red beads, and that rate will not decrease until the percentage of red beads is reduced or eliminated from the system. Where fault lies Are you skeptical about this take on human error? That's understandable, because humans are indeed fallible. That's why we must take preventive steps to insulate our systems .E. Deming's research shows that far fewer than 20 per- cent—and more likely fewer than 10 percent—of errors have as their root cause a human element [1]. Rather, it's system variation that drives the true error rate. That idea is encapsulated in a quotation attributed to but never uttered by Deming: "A bad system will defeat a good person every time." A report from the US Naval Safety Center states that, "Human error has been implicated in 70 to 80 percent of all civil and military aviation accidents" [2]. Yet the report also notes that the real story is counterintuitive and complicated, and much of what we consider across many industries to be human error is not. Likewise, some of what we consider not to be human error truly is. f-Locwinart_24-35_Masters 7/2/14 1:29 PM Page 24