People make mistakes, and those mistakes creep into your business processes to erode the quality of what your people do, how they think, and what they produce.
Human error and the consequences of human error (system sensitivity) need to be understood in context with one another. Human error and system sensitivity are two interdependent partners. Human error does not have its origin in the perversity of human nature nor is it secreted from the human error gland. Human error is normal performance which, when molded by factors both internal and external to the human, turns into incorrect performance. The system in which the human operates is either sensitive to the incorrect performance or insensitive to it. If the system is sensitive to the change in human performance, then we label the outcome as human error. If the system is insensitive to the change in human performance there is not any human error, even though the incorrect performance was the same. Yogi Berra, the famous reliability engineer was correct when he said, “I don’t want to make the wrong mistake!” Some performance variations matter, but most don’t.
Compare human error in commercial air travel and human error in hospitals. The transportation industry has spent decades addressing human error causation and has implemented many barriers to prevent catastrophic loss of life. if you fly every day of your life, probability indicates that it would take you nineteen thousand years before you would succumb to a fatal accident. By contrast, 440,000 patients each year who go to the hospital suffer some type of preventable harm that contributes to their death. Medical errors are the third-leading cause of death in America, behind heart disease and cancer. What are some of the differences between air transportation and healthcare?
There are no language competency tests for physicians in the U.S., there are for commercial pilots. There are no hours of work limitations for physicians in the U.S., there are for commercial pilots. There are no random drug tests for physicians in the U.S., there are for commercial pilots. There is no minimum time between alcohol ingestion and beginning of work for physicians in the U.S., there are bottle-to-throttle limits for commercial pilots. The modern jet airliner has approximately 125 items to check before hitting the start switch. Your surgeon starts on you as soon as the last patient is rolled out. There are no mandated vision tests for physicians, there are for commercial pilots. Flight physicals are mandated every 12 calendar months for a pilot under 40, and every 6 months for pilots over 40. There is no mandate for physicians.
Human error has distinct causation and can be managed and reduced.