Es el ultimo día para sacar la producción, todo el mundo esta corriendo de un lado a otro para lograrlo. A última hora los documentos finales no aparecen. Alguien los perdió. Por arte de magia nuestro superman organizacional hace lo imposible para, localizarlos crearlos, recrearlos…¡¡¡lo que sea!!!  Finalmente lo logra. He aquí nuestro gran héroe… nuestro salvador organizacional… Le felicitamos en la reunión, le dejamos saber cuan valioso es para nuestra organización, y publicamos la hazaña… ¡imagínense! Si no fuera por él/ella la producción no salía y le costaría una millonada a la organización.

¿Les suena esto familiar?
Normalmente nos encontramos en organizaciones con un batallón de “bomberos”…  Son lo que a diario se aquejan de que se la pasan apagando fuego.  No tienen tiempo de planificar, a mitad de una reunión tienen que salir a atender llamadas de emergencia, los celulares no dejan de sonar, son interrumpidos constantemente en los adiestramientos; en fin; siempre están ocupados “resolviendo…”

Yo me pregunto: ¿que bombero esta todos los días, a toda hora y de forma constante apagando fuego?  ¿Que bombero es interrumpido cuando esta tomando un adiestramiento?

Entonces… ¿por qué las organizaciones hoy en día sufren constantemente del síndrome del fogón? He aquí algo a considerar. Los seres humanos necesitan ser reconocidos, admirados, motivados y alentados. Todos sabemos que sentirnos bien y contentos nos permite que la intensidad y calidad de nuestro trabajo aumente de forma considerable.

El diccionario de psicología de Oxford define motivación de la siguiente forma:
Una fuerza que nos dirige y es responsable del inicio, persistencia, dirección y vigor de la conducta dirigida al cumplimiento de una meta. Incluye factores biológicos de supervivencia y factores sociales como la necesidad de logro y afiliación.Los teóricos como Maslow, Hull, Hertzberg, etc. que han trabajado los conceptos de motivación en la psicología concuerdan en que la necesidad de logro y reconocimiento es un factor dominante en nuestra conducta.

Por esto opino que nuestros héroes que sufren del “síndrome del fogón” de forma inconsciente pueden crear cada vez mas y más actos heroicos, buscando satisfacer su necesidad de reconocimiento y premiación.

Con esta opinión no insinúo que no trabajan fuerte, ciertamente si lo hacen pero de forma reactiva. No obstante los héroes invisibles, los verdaderos bomberos organizacionales, los que trabajan con prevención, educación y Planificacion; rara vez causan un fuego. Pasan totalmente por desapercibidos, no son reconocidos y casi nunca los conocemos.

Estos son los que hacen el trabajo de los líderes más fácil ya que las cosas corren de forma normal y no hay alarmas a las que reaccionar. Sin embargo luego de notar que el reconocimiento es limitado terminan convirtiéndose en los reactores de los que hablamos.

Si bien es cierto que ninguna de estas transacciones mentales se da en un plano consciente, también es cierto que los planes de reconocimiento son diseñados considerando elementos que ayuden a la organización a mantener motivados a los empleados.  Debemos tomar en consideración que los elementos de juicio para el reconocimiento de logros deben dirigirse a premiar dimensiones como planificación, prevención, adiestramiento y todos aquellos elementos que silencian las alarmas que nos hacer reaccionar, constantemente.

En la medida en la que se invierta tiempo y energía en el refuerzo de las conductas que esperamos poco a poco tendremos reales bomberos organizacionales… los que están listos para reaccionar solo a una verdadera emergencia.

These are some of the questions organizations ask themselves all the time.  Human Error has become the major contributor for failures, yet we don’t seem to understand it, let alone… correct it!

By implementing a quantitative methodology for root cause determination, not only you will be able to know what’s happening …but correct it!, and you’ll  also be able to make decisions based on empirical data, measure the effectiveness of the solutions implemented, and track  the progress and sustainability of  all the improvements made. 

The article goes on to stress that it’s not enough to attribute the cause of an adverse event to “human error.” Here’s what they say:

”Attributing adverse events to human error is too often the final step in the investigation, when in fact it should be simply the first step in understanding how and why such failures occur.”

They close the article with five prescriptions for success in achieving patient safety:

- First, recognize that failures can and will happen in any system. No one is immune. Look for and find the vulnerabilities in your system through purposeful, interdisciplinary effort.
- Second, understand the problem before you fix it. Applying apparent solutions before you understand the many facets of a problem ensures failure.
- Third, fix the whole system, not just the immediate problem. Chalking an incident up simply to “human error” will give you an incorrect, incomplete or shallow explanation.
- Fourth, simplify, don’t complicate. Make it easier for people to do it right, and harder for them to do it wrong. Simplifying the operation of a system can dramatically improve its reliability by making it easier for the humans in the system to operate effectively.
- And fifth, instead of blaming people, help them to do it better. The authors close the article by saying that the most effective prescription for healthcare system improvement is to support people as they perform their day to day tasks.

Additional Information:
Billings, CE and Woods, DD. Human Error in Perspective: The Patient Safety Movement. Postgraduate Medicine – Vol. 109, No. 1: 13-17. January 2001.

Human errors are definitely actions performed by individuals. Nevertheless, most of the time individuals behave in a certain way because of factors external to the individual.  Those external factors are called conditions. Humans operate in direct proportion to their conditions. If conditions are imperfect, so will be human execution. If conditions are more that imperfect, the executions are going to be more that imperfect, and so on…

By identifying which are those conditions that make people behave in a certain way; you can modify behavior and get the results you want.

Organizations have the results they have designed for themselves. By taking a closer look at your processes, procedures and organizational factors, you can re-design your operation and make it a complete success!

• Human Error is 20% human and 80% bad designed systems

• Less than 8% of human errors are related to a lack of Knowledge, Skill or Ability? (Training)

• Less than 10% of human errors are related to the individual that actually executed incorrectly?

• More than 70% of the corrective actions for human errors are to re-train?

• On Fatigue: 17 consecutive hrs/work produces same error rate as 0.05mg/l alcohol in bloodstream.

• More than 90% of organizational failures are caused by an incorrect action performed by a human?

• ”Human error” is about explaining “human behavior” in the same way chemical engineers explain product behavior.

• Did you know ‘Human Error’ shows up in about 80% of aviation accidents? Did you know it can be prevented?

Too many organizations spend significant energy and time trying to “fix” the people. Too many grab hold of the latest management fad without considering the fact that each organization has its own culture and not all solutions are “one size fits all”.

Your situation is unique, and most likely is a very simple problem, manifested in a very complex system. We will help you figure out what is the “best solution” for you.

Curious and passionate about the use of common sense and making complex things simple, and by working for pharmaceutical manufacturing companies in the training and development function, answers to many questions regarding human performance and productivity were found. Since then, we have specialized in making sense out of those human related performance issues that affect productivity, and fixing them to improve organizational results.

Most of the wisdom and expertise needed already exists in organizations. Most people come to work committed to do things right and do the right thing, and they are the ones that hold the answer to most of the secrets to an organization’ success.

The challenge is to have them to “want to” work towards excellence and productivity and proactively eliminate obstacles that are embedded within the organizations systems and processes. By working with an organizations’ spinal cord “the people”, we have help companies achieve and even exceed their business results.

• Reducing Human Error on the Manufacturing Floor
http://tinyurl.com/ykgr34c

• 5 requisitos para ser buen jefe 
http://www.elnuevodia.com/5requisitosparaserbuenjefe-714882.html

• Limitado el Multitasking en los seres humanos
http://tinyurl.com/397ovjf 

• El oneroso costo del error humano
http://www.elnuevodia.com/elonerosocostodelerrorhumano-616860.html

Edition: August 20, 2009 | Volume: 37 | No: 33

Preventable mistakes can add up to millions in losses

It takes a toll every day in the workplace, yet little attention is paid to it—the cost and impact on businesses of human errors.

Companies in the mainland U.S. lose an estimated $3.6 million daily due to human error, which translates into more than $1 billion annually. Only 16% of organizations measure the cost of human errors. The remaining 84% don’t measure it and most pay the price without knowing it.

There are no statistics in Puerto Rico to shed light on just how much local companies are losing due to human errors, but the numbers are likely alarming.

“In less than a year, 60% of human errors can be eliminated in an organization if there is a proper intervention of its systems. Approximately 95% of human errors are due to the design of a company’s systems. It can be from the simplest, most sublime, to the most complicated,” said Ginette Collazo, who holds a doctorate in industrial / organizational psychology.

Collazo is one of a relatively small group of human reliability experts and the only Puerto Rican expert on human error selected by the Tennessee-based Process Improvement Institute as an instructor.

With more than 10 years’ experience in technical training, organizational development and human reliability fields in the pharmaceutical industry, Collazo built on her unique expertise in the mainland U.S. through consulting work with nuclear and other high-risk industries where there is little tolerance for human errors.

Collazo understands what works and what doesn’t when trying to change a culture from an error-tolerant environment to an error-free learning organization.

According to Collazo, although the foundation of human-error prevention rests on job safety, the impact of human errors can affect any organization’s bottom line.

Collazo said the issue has even more relevance in the workplace in light of current economic conditions.

“Companies are downsizing, which doesn’t necessarily translate into rightsizing. For example, you can reduce jobs for budget reasons, but the activity of work increases for those who are left in a given company, which increases the possibility of errors. There is more stress because of more work, not to mention the emotional stress of wondering if they are next to be laid off,” Collazo said.

• Interphex 2010: Human Factors and Errors: FDA Compliance, Training and Human Reliability.
http://interphexpr2010.conferencepath.com/speakerlist/?action=showsessions&userid=36813

• Webinar: “Reducing Human Error on the Manufacturing Floor”
http://tinyurl.com/2dq7nkh