Human Error; Human Error Prevention; Error; Human Performance; Human Performance Improvement; 
Root Cause Analysis; Corrective Action; Process Improvement

HUMAN ERROR PREVENTION
By BW (Ben) Marguglio

Bookinar™ Outline:

•  Terminology and definitions

•  Behavior model 

•  Classifications of human error

•  Quality and safety culture  

•  The quality- and safety-conscious work environment                         

•  The total quality and safety function

•  The seven human error causal factors                            

•  Models of event prevention

•  The four levels of error

•  The three levels of barriers to error

•  The types of barriers that can be implemented at the three levels

•  The relationship of barriers to the total quality and safety function

•  Process design criteria

•  Techniques for strengthening barriers

•  Poka yoke

•  Sources of error-inducing conditions and error-likely situations

•  Types of error-inducing conditions and error-likely situations

•  Behaviors to counteract error-inducing conditions and error-likely situations

•  Thought processes and behaviors leading to non-conservative decision-making

•  Thought processes and behaviors for conservative decision-making

•  Coaching to reduce human error recurrence

•  Problem reporting, root cause analysis, and corrective action system objectives

•  System participant responsibilities

•  System capabilities

•  Problem data collection criteria

•  Standard data tables / Data to be collected, and why

•  Fact versus conclusion

•  Extent of problem analysis

•  Operating experience

•  Risk-based initial screening of problem reports

•  Risk, urgency and significance

•  Root, contributing and direct causes

•  Criteria for action

•  Administration of root cause analysis

•  Data collection

•  Interviewing

•  Root cause analysis

•  Change analysis  

•   Failure mode & effects analysis

•   Hazard-barrier-effects analysis

•   Cause & effects analysis / Fishbone diagrams

•   Time-line analysis

•   Probabilistic risk or safety analysis, with event & fault trees

•   Management & oversight risk tree analysis

•   Process flow diagrams

•   Value stream diagrams

•   Other

•  Hardware failure modes

•  Hardware failure causes

•  Human performance root causes

•  Extent of cause analysis    

•  Types of corrective actions

•  Elements of a corrective action commitment

•  Corrective action verification

•  Leading and lagging performance indicators

•  Performance and status indicator reports

•  Defense in depth

•  Review of Marguglio’s theorems and principles