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HUMAN ERROR
PREVENTION
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Bookinar Outline: Terminology and definitions Behavior model Classifications of human error The seven human error causal factors Model of event prevention four levels of error and the three levels of barriers to error and hazards Total quality and safety matrix relationship of barriers to the total quality / 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 Analysis for extent of problem 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 Analysis for extent of preventive corrective action 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 Marguglios theorems and principles
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