human error training

Want to Reduce Human Error? Just Change Your Habits

NSF International, Pharma Biotech

Want to Reduce Human Error? Just Change Your Habits

By Martin Lush, President, NSF Pharma Biotech Consulting

When companies undertake initiatives to reduce human error, they often ask themselves ‘Why do people make mistakes?’ One major reason is the power of habit. We are all creatures of habit, taking actions without really thinking about them. For example, have you recently:

> Changed the position of the icons on your children’s iPhone?

> Moved things around in your kitchen cupboard without telling your partner?

> Taken a new route to work?

> Added a minor change to an established instruction?

> Changed the position of a piece of equipment, dial or gauge?

> Altered the flow of a well-established process?

> Added additional detail to your batch manufacturing record?

If you’ve done any of these things, mistakes and errors probably happened. This is because old habits (behaviors) stick in the face of new procedures. When you change an established routine, swapping the old for the new, mistakes will happen. Here’s why.

HABITS: Some essential facts and why any change creates a risk of ‘error’

> A habit is when we act without consciously thinking. Like following an old SOP, batch record or the normal route to work.

> Habits are vital to our very survival. They prevent our brains from overload and save precious energy so we can focus on new, unfamiliar tasks.

> Habits are created by repetition. The simpler the routine, the easier the habit. For example, drinking water with every meal would take 20-30 repetitions before it became an automatic behavior. More complex routines and tasks require many hundreds of repetitions before the new habit is formed.

> Once learned, a habit is activated by a cue, or trigger.

 The phone rings, you answer it.

 You get into your car and put on the seat belt.

> Once established, habits are hard to change, but they can be replaced by a stronger habit. Think of a habit as a river. You can’t suddenly stop it… you need to encourage it to change course.

> However, old habits remain dormant and can be quickly fired up, particularly by familiar context and surroundings, even when the new habit is learned.

> We always follow our strongest habit, particularly when our willpower is weakest when we’re tired or stressed.

Some Hints for Success: Your “Six to Fix”

> When you are about to change an established way of working, ask yourself if it is really worth the risk. Some documentation changes are so minor and insignificant they really are not worth it. The risks are too high. Remember, easy tasks are easy to habituate. Keep things simple. Design processes so they are easy to habituate. > If you do go ahead, highlight documentation changes in red, to act as a trigger or cue that forces the brain to stop and consciously think. Symbols are useful as well.

> Try to standardize equipment design. The start and stop controls should always be in the same position and look and feel the same. Don’t let equipment suppliers “upgrade” by moving controls around.

> When you change something invest in dedicated practice to strengthen the new habit. The first 20 hours is vital. You just need to invest 40-50 minutes each day. If you’re convinced you don’t have the time, remember how many costly errors happen because new SOPs are rushed in. Prevention is always better (and cheaper) than reaction.

> When you change something, expect people to make mistakes. It’s normal. Remember, old habits remain dormant and potentially surface when the pressure is on. Practice must be precise and supported by coaching, feedback and lots of patience. It’s staggering how many companies still use the “read – understand” approach to SOP training and implementation. It just doesn't work. Old habits will resurface and mistakes will happen.

> If you can, engineer out the old habit. Make it physically impossible for the old behavior or routine to be followed through interlocks, screens, barriers, alarms and the like.

Next Steps and Human Error Resources

·         Have a look at the six-minute YouTube video. https://youtu.be/X52ajEoQf-s

·         Take a look at our prerecorded webinar: 'Changing Behaviors in the Workplace’' http://youtu.be/HtAzW_cxZGg

·         If you’re interested in finding out more about changing work place behaviors (habits), contact NSF

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