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Why the "train or punish" model doesn't work |
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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 |
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What the Error Prevention Hierarchy is and how to use it |
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Categorizing Human Errors to enable analysis, correction and prevention |
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Category 1: Learning Gap Errors – people don't know, didn't learn properly |
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Category 2: Memory Gap Errors – people know but can't remember |
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Category 3: Inconsistency Errors – variability in how people do things |
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Category 4: Application Errors – slips, trips, people know how to do it but make mistakes |
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Category 5: Omission Errors – omissions in forms & paperwork, omissions in procedure |
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Category 6: Decision Errors –inappropriate decisions made given the situation |
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Case Studies: Documentation Errors, Process Errors. |
