 |
Why the "train or punish" model doesn't work |
|
How to identify which errors are due to "human factors" and which are due to system design that conflicts with how the human brain works |
|
What the Error Prevention Hierarchy is and how to use it |
|
Categorizing Human Errors to enable analysis, correction and prevention |
|
Category 1: Learning Gap Errors – people don't know, didn't learn properly |
| |
 |
Overview of brain physiology |
|
Role of the Reticular Activating System in learning |
|
How different types of information are processed and which information is processed faster, more accurately (words, symbols, colors, digits, sequences, pictures, sounds..) |
|
How processing conflicts occur in the brain and how to minimize them |
|
Physiology of learning (neural pathways, anchoring, senses, emotion..) |
|
For new learning, which should be covered first: conceptual/theoretical or physical? (Relevance for induction programs) |
|
Covering what can go wrong - when and how it should be done. |
|
|
Category 2: Memory Gap Errors – people know but can't remember |
| |
|
Determining the level of learning required for a given situation |
|
Recognition versus Recall – what's the difference and why is it important? |
|
Assessing for Recall is different to assessing for Recognition |
|
The role of multiple-choice assessments – when not to use them |
|
Habits and auto-behaviors stored in different part of the brain – implications for errors and how to deal with this |
|
Physiological factors related to memory and how to minimize risk of memory errors |
|
|
Category 3: Inconsistency Errors – variability in how people do things |
| |
|
Determining if inconsistency is present and "setting the standard" process |
|
The role of perceptual memory distortion in inconsistency errors |
|
Color memory – why it is not possible to use color memory for quality checks |
|
Memory fills in gaps– issues with inconsistency and how to prevent them |
|
Visual memory issues – why you need to code details using “verbal descriptions” in memory |
|
|
Category 4: Application Errors – slips, trips, people know how to do it but make mistakes |
| |
|
Cognitive Load – what this means and why it is the leading cause of Application Errors |
|
Transcription Errors – Why they’re caused and how to prevent them |
|
Perception errors – conflicts and how to prevent them |
|
Colors, symbols, words – how to use them effectively to reduce cognitive load |
|
Document layouts that reduce cognitive load and minimize errors |
|
Auto-behaviors and Application errors – how to prevent them |
|
|
Category 5: Omission Errors – omissions in forms & paperwork, omissions in procedure |
| |
|
Attention Activation – what is it and why it is the leading cause of Omission Errors |
|
How fields and document layouts can be used to avoid Omission Errors |
|
Role of color, symbols, shapes and words in Attention Activation |
|
Using triggers and focusing aids to prevent Omission Errors |
|
Analyzing & designing documents for effectiveness in layout and triggers |
|
Case studies on process errors |
|
Case studies on document errors |
|
Why proof-reading is error-prone |
|
Boundary errors – what are they and how to prevent them leading to omission errors |
|
|
Category 6: Decision Errors –inappropriate decisions made given the situation |
| |
|
Understanding the Goal-Perception-Decision-Processing model |
|
All decisions must pass through Limbic system in brain – what this means and how this leads to errors |
|
Goal clarity – all goals are ‘translated” by the brain - ensuring clarity |
|
Balance of Consequence model impacting decisions |
|
Altering the balance of consequence |
|
Social Proof – what it is and how it leads to Decision Errors |
|
Dilution of Responsibility – what it is, how it leads to Decision Errors, relevance to “turning a blind eye” |
|
Dilution of Responsibility – relevance to verification and checks by multiple people |
|
|
Case Studies: Documentation Errors, Process Errors. |
