Por: Dra. Ginette M. Collazo
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.
Why Human Error events keep increasing?
Why do people keep making the same mistakes?
What is the investigation about anyways… the human or the quality failure?
How “deep” does the root cause determination process has to go?
Is Human Error the conclusion or the beginning of the investigation?
If the CAPA effectiveness metric is telling a good story, why do we keep having so many failure events?
From the FDA Site…
We also want to call your attention to an interesting article by Drs. Charles Billings and David Woods, in the January 2001 issue of Postgraduate Medicine, called “Human Error in Perspective.”
The article starts out with a little history of the so-called “patient safety movement,” including the influence of the famous report of the Institute of Medicine in 1999, with its disturbingly large estimate of patient deaths due to medical error.
Organizations are investing more than 70% of their efforts in less than 10% of their problems.
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…
Did you know that…
• 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)
Human related performance issues refer to all those things that people do (or don’t) that adversely impact organizational results (goods, products, service, etc.). These can either be internal or external to the individual itself. Human error, inefficiencies in processes, non value added activities, bureaucracy and resources constraints are just a few of the things that could be affecting productivity in your organization, manifested by human performance failures.
So valuable that workforce itself can either make or break any organizations success. People definitely impact business results and productivity.
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.
• Accountability & the Employee Empowerment Myth
• Reducing Human Error on the Manufacturing Floor
By : LAWSON D. THURSTON / firstname.lastname@example.org
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.
• Seventh Annual Medical Device Quality Congress: Reducing human error in the manufacturing floor.