What is Human Error?
Human error is, in a nut shell, an action or a failure to act that leads to an unwanted outcome.
Examples of Human Error
- Missing a dilution in sample preparation (failure to act), leading to invalid test results (unwanted outcome).
- Using a 250ml volumetric flask instead of a 200ml volumetric flask for sample preparation (action), leading, again, to invalid test results (unwanted outcome).
Science, with all its controls and measures, is often believed to be above human error. Yet in a laboratory where everything is documented, checked and double checked by trained humans, errors still occur. Acknowledging that human error is more than a failure of an individual brings it out from the shadows. It changes from a topic of shame, to an opportunity for progress in the form of human error risk reduction.
What factors cause Human error?
There are two separate factors that can cause human error:
- Stressors (personal)
- Structural (environment)
The stressor (personal factor) in both of our examples could be a lack of concentration on the part of the analyst and by investigating further the cause of the error might be due to the analyst having a bad night’s sleep. This is a perfectly reasonable explanation and is easy enough to identify as the root cause of the invalid results. But how are we going to fix the root cause? There’s no way to guarantee a good night’s sleep prior to preparing samples again. Even though we know the reason behind the invalid results we can’t prevent it happening again.
Structural Factors for Human Error
When we look a bit further, we arrive at the structural factors. As the name suggests these factors are controlled by design, reorganisation and the sort of activities usually associated with problem-solving. The structural factor in our dilution example might be the wording or presentation of the instructions, or the manner in which the volumetric flasks are stored and identified. So although we can’t do much to prevent the stressors we can address the structural factors.
How do BCM improve Structural Factors?
Here at BCM we have learnt from Human error and have put CAPAs in place following Investigations and Deviations. Simple changes in laboratory lay out help remove simple issues.
Example - Separation of 200ml Volumetric Flasks and 250ml Volumetric Flasks reduces the risk of analysts selecting the wrong equipment.
Investigations and Deviation CAPAs are a great way of stopping an error re occurring, but there are also things you can do to prevent the errors occurring the first place. One way BCM prevent errors occurring through structural changes is via 5S. Regular internal and external 5S audits helps keep the laboratory area safe, organised and helps find structural factors that can improve efficiency.
Embracing Human Error
Encouraging open dialogue concerning human error creates a culture where stressor factors are recognised and structural factors are challenged. By avoiding using the stressors as an excuse to apportion blame and focusing on fixing the structural factors it is possible to decrease human error.
By accepting and embracing human error, we are able to recognise that our systems, procedures and environment design may require regular review. Assessing and improving the environment we work in is a key and continuous task to ensure that error is minimalized and productivity is increased
Here at BCM Analytical Services, we are always looking for new and creative ways to give our customers the best possible service. We are constantly looking to improve our processes to ensure right first time (RFT) and on time in full (OTIF).
