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The document discusses the inadequacy of blaming 'human error' as a root cause in quality management, emphasizing the need for deeper analysis. It categorizes errors into thinking errors, action errors, and risk-based errors, suggesting solutions such as improved training, intuitive task design, and fostering a culture prioritizing safety. The focus is on identifying underlying causes and implementing preventive measures to enhance overall quality and performance.

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7 views2 pages

? ???? ?? ???? ?????? ???????????? "????? ?????" ???? ?????

The document discusses the inadequacy of blaming 'human error' as a root cause in quality management, emphasizing the need for deeper analysis. It categorizes errors into thinking errors, action errors, and risk-based errors, suggesting solutions such as improved training, intuitive task design, and fostering a culture prioritizing safety. The focus is on identifying underlying causes and implementing preventive measures to enhance overall quality and performance.

Uploaded by

lungmarkus
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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𝟑 𝐊𝐞𝐲𝐬 𝐭𝐨 𝐦𝐨𝐯𝐞 𝐛𝐞𝐲𝐨𝐧𝐝 𝐔𝐧𝐚𝐜𝐜𝐞𝐩𝐭𝐚𝐛𝐥𝐞 “𝐇𝐮𝐦𝐚𝐧 𝐄𝐫𝐫𝐨𝐫” 𝐑𝐨𝐨𝐭 𝐂𝐚𝐮𝐬𝐞 🎯

It’s easy to blame “human error” when things go wrong, but in quality management, this isn’t an
acceptable root cause.
Why? Because labeling something as “human error” doesn’t lead to improvement—it just stops the
conversation.
To truly solve the problem, we need to dig deeper and ask, what can we do to prevent this error from
happening again?
Let’s break this down into three categories of errors and explore how we can move beyond “human
error” as an explanation:
1. 𝙏𝙝𝙞𝙣𝙠𝙞𝙣𝙜 𝙀𝙧𝙧𝙤𝙧𝙨:
This happens when individuals make decisions based on incorrect assumptions or incomplete
information.

Instead of blaming human error, ask:


• What led to this wrong decision?
• Was there a lack of training or unclear communication?
• Was the procedure too complex or confusing?

Solution:
• Provide better training to ensure people fully understand the task.
• Simplify or clarify procedures to avoid misunderstandings.

2️. 𝘼𝙘𝙩𝙞𝙤𝙣 𝙀𝙧𝙧𝙤𝙧𝙨:

These occur when a person knows what to do but doesn’t perform the task correctly—like pressing the
wrong button or missing a step.

Instead of blaming human error, ask:


• What caused the mistake?
• Was there a lack of focus due to distractions or fatigue?
• Were the instructions unclear or too complex to follow correctly?

Solution:
• Design tasks and interfaces that are intuitive and reduce the chance of error.
• Eliminate distractions and improve working conditions to support focus.

3. 𝙍𝙞𝙨𝙠-𝘽𝙖𝙨𝙚𝙙 𝙀𝙧𝙧𝙤𝙧𝙨:
These are errors made when someone takes shortcuts or risky actions to save time, often due to
pressure or inadequate resources.

Instead of blaming human error, ask:


• Why was this risk taken?
• Was there a lack of resources or excessive time pressure?
• Did the individual feel unsupported or unsure about the right course of action?

Solution:
• Improve processes to ensure enough time and resources are available to do the job right.
• Foster a culture where safety and quality are prioritized over shortcuts.

𝙄𝙣𝙘𝙤𝙧𝙥𝙤𝙧𝙖𝙩𝙞𝙣𝙜 𝙖 𝙧𝙞𝙨𝙠-𝙗𝙖𝙨𝙚𝙙 𝙩𝙝𝙞𝙣𝙠𝙞𝙣𝙜 𝙖𝙥𝙥𝙧𝙤𝙖𝙘𝙝 𝙞𝙣𝙘𝙡𝙪𝙙𝙚𝙨:

• Identifying and mitigating risks in processes before they lead to mistakes.


• Empowering teams to report near-misses without fear of blame.
• Continuously improving systems to prevent errors at every level.

📢Have you encountered situations where human error was the first explanation?

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