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WO2008138134A1 - Procédé permettant d'évaluer et de communiquer un risque d'erreur humaine organisationnelle et ses causes - Google Patents

Procédé permettant d'évaluer et de communiquer un risque d'erreur humaine organisationnelle et ses causes Download PDF

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Publication number
WO2008138134A1
WO2008138134A1 PCT/CA2008/000927 CA2008000927W WO2008138134A1 WO 2008138134 A1 WO2008138134 A1 WO 2008138134A1 CA 2008000927 W CA2008000927 W CA 2008000927W WO 2008138134 A1 WO2008138134 A1 WO 2008138134A1
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WO
WIPO (PCT)
Prior art keywords
awareness
operational
organization
human error
error
Prior art date
Application number
PCT/CA2008/000927
Other languages
English (en)
Inventor
Martin J. Smith
Original Assignee
Presage Group Inc.
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Presage Group Inc. filed Critical Presage Group Inc.
Publication of WO2008138134A1 publication Critical patent/WO2008138134A1/fr
Priority to US13/051,458 priority Critical patent/US20110307293A1/en

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Classifications

    • G—PHYSICS
    • G06—COMPUTING; CALCULATING OR COUNTING
    • G06Q—INFORMATION AND COMMUNICATION TECHNOLOGY [ICT] SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES; SYSTEMS OR METHODS SPECIALLY ADAPTED FOR ADMINISTRATIVE, COMMERCIAL, FINANCIAL, MANAGERIAL OR SUPERVISORY PURPOSES, NOT OTHERWISE PROVIDED FOR
    • G06Q10/00—Administration; Management
    • G06Q10/10—Office automation; Time management

Definitions

  • This invention relates to the field of industrial psychology, and in particular, the field of human error.
  • Human error is a source of heavy economic costs, injury and death in many different fields, and there are certain fields in which human error can have particularly catastrophic results. Examples include aviation, medicine, pharmacology, nuclear energy, transportation, emergency response services (police, fire, ambulance), military, security services, manufacturing, and supply distribution.
  • FMEA Failure Mode and Effects Analysis
  • FMEA is used to select remedial actions that reduce the risk of errors, as well as the impact of the consequences of those errors.
  • the three basic parameters in FMEA are (1) severity (S); (2) likelihood of occurrence (O), or probability (P); and (3) inability of controls to detect the error (D).
  • S severity
  • O likelihood of occurrence
  • P probability
  • D inability of controls to detect the error
  • RPN Risk Priority Number
  • the RPN is used to prioritize all potential failures and to decide upon actions that reduce the risk of the failure, usually by reducing likelihood of occurrence and improving controls for detecting the failure.
  • FMEA does not attempt to determine the causes of errors. Rather, FMEA is focused exclusively on error rates and severity of consequences. Thus, an organization may be aware of what types of errors happen most often, and cause the most severe damage, but using only FMEA gives little guidance on what steps to take to prevent the errors from happening. The result may be that the organization takes action to prevent error, but the action is unrelated to the actual cause, and is therefore ineffective.
  • a method of preventing human error in an organization comprising: making a plurality of collections of psychosocial awareness factor data over an error prediction time period from individuals performing tasks within the organization; accessing human error data relating to the error prediction time period on human error incidents within the organization; using the human error data and psychosocial awareness factor data to determine whether the level of one or more awareness factors predicts human error; if said one or more awareness factors predicts human error, notifying the organization of the nature of the human error predicted, and of the one or more awareness factors that are the cause of the human error.
  • Anticipatory Awareness - awareness that imagines and anticipates possible scenarios. Such awareness includes, for example, the forecasting of potential situational variables and their movement, and the ability to imagine multiple scenarios while interpreting the implications and consequences of each.
  • Task-Empirical Awareness - awareness of how to assess for the "normal" operation of the task at hand involves, for example, the individual understanding the normal operational limits of the task for him, and taking steps to maintain himself within those normal operational limits.
  • Affective Awareness - awareness of how one's emotions, feelings and/or sensory experience informs safe operation. This involves, for example, both awareness of one's own emotional state, and knowing that shifts in the feeling or emoting experience of an individual signal a situational change which may require adaptation.
  • Compensatory Awareness - awareness that causes the individual to adjust or compensate for situational variables.
  • This type of awareness is the product of flexibility and accommodation within the individual in order to maintain safe operation given specific situational dynamics. Thus, for example, this type of awareness would cause the subject to knowingly modify their behaviour in response to operational distractions such as, for example, disruptive behaviour, loud external noises or catastrophic events.
  • An individual having this type of awareness typically makes an immediate adjustment in thinking and behaviour to accommodate for situational conditions that the individual has read and interpreted.
  • Critical Awareness - awareness that causes and individual to assess and evaluate the task at hand against his own bank of experience. So, for example, an individual with high Critical Awareness would likely have a clear understanding of the risks associated with working while sleep-deprived or medicated. Such an individual also knows, from experience, what operational pace is appropriate to ensure safety. Similarly, other aspects of his experience are used by the individual to assess and evaluate the present task at hand.
  • Relational Awareness - awareness for how the "other" influences safe operations. This type of awareness can have a number of different aspects. Thus, for example, if a particular individual feels that his concerns about safety are less important than other people's concerns, then he may lack Relational Awareness. An understanding of the value of team cohesion in operational success and in safety is an aspect of Relational Awareness.
  • Relational Awareness would typically include clearly understanding the roles played by each individual in the completion of the task.
  • Functional Awareness - awareness for the meaning or function of objects of the individual's experience. Thus, being aware of why the individual would don a mask during air plane depressurization is example of Functional Awareness.
  • risk of human error in an organization 10 is determined by making a plurality of collections of psychosocial awareness (reference numeral 14) factor data over an error prediction time period from members of organization 10.
  • This data is preferably held in a database 16, providing the resources for storage and analysis of the data.
  • members of the organization 10 will be asked a selection of questions at least four times per year, though it will be appreciated that higher or lower frequencies are possible, depending on the circumstances.
  • the questions are selected to determine the levels of the awareness factors described above. Also, because each member answers such questions periodically over time, the changes in the awareness factors among the organization members over time can be tracked.
  • each individual answers a subset of the inventory each time data is collected from him, so that after a pre-selected number of data collections (e.g. four per year), he has answered the entire inventory of questions.
  • questions from the inventory are not asked of each organization member in the same order. Most preferably, after the first data collection, each of the questions of the inventory will have been asked of at least one organization member.
  • This approach is preferable, because data on every aspect of each type of awareness becomes immediately available on all aspects of each psychosocial construct, and it may be possible, depending on the sample size and other statistical parameters, to be able to draw valid conclusions from the data even though each member has not yet answered all, or even most, of the questions in the inventory.
  • organization members will answer questions confidentially or anonymously, using an internet-based questionnaire provided to them.
  • questions relating to psychosocial constructs often demand an answer that could make an individual fear discipline or dismissal.
  • An individual may also have an incentive to answer the question dishonestly to make himself look better than he actually is, hoping that the organization see his answer and think more highly of him.
  • Affective Awareness an individual may be asked whether he tends to deny the negative effects of exhaustion on his performance. An individual facing such a question may legitimately fear negative consequences from answering in the affirmative.
  • an individual may be asked to agree or disagree with the statement, "I will not ignore the performance shortcomings of my peers and coworkers.” The individual may be tempted to agree with this statement even if the answer is false, hoping that his employers will see him as an exceptional employee with leadership potential. Thus, the shielding of the identity of the employee is helpful for encouraging honest responses. It is preferred that individuals know that their answers will not have any impact on their individual employment, whether positive or negative.
  • Collecting data repeatedly and periodically over time can also provide information on changes in the risk of human error over time, and possible strategies for reducing the risk.
  • the levels of one or more types of awareness may change over time, indicating a progressively growing risk of human error.
  • collection of data over time may show that a particular subset of the organization has declining Anticipatory Awareness.
  • One of the factors associated with Anticipatory Awareness is familiarity with co-workers and team members. A typical worker will have greater Anticipatory Awareness when working with familiar team members with whom he is comfortable. In this example, it may turn out to be the case that this same subset of the organization has seen substantial turnover of personnel in the recent past.
  • the safety officer can be notified of the risk, together with a recommendation that measures be to increase familiarity and comfort between the workers in the particular subset of the organization.
  • making a plurality of data collections over time has a number of advantages.
  • the repetition of the data collection provides greater confidence that the data collection can be validly generalized to the population of the institution being studied.
  • a second benefit of a plurality of awareness data collections is that if one or more events occur which negatively affect one or more types of psychosocial awareness, then it may be possible to observe this problem developing before it becomes particularly acute, and thus to remedy the problem before it becomes more serious.
  • a second benefit is that it is more likely that the developing awareness problem can be traced to a particular event or events, and this information can be used to develop safeguards for permanently preventing recurrence, even if the triggering event recurs.
  • a third advantage is that, once a proposed solution to the awareness problem is implemented, continuing to collect data periodically and repeatedly over time allows the organization to see if the proposed solution worked. If it did, then the continued data collection should show an improvement in the awareness that was previously lacking.
  • all error incident reports generated by the organization are provided to the database (reference numeral 12), so that data regarding human error in the error prediction time period can be accessed and used in association with data collected regarding psychosocial factors. Most preferably, they are also entered onto a website questionnaire form for uploading to the database 16.
  • other modes of receiving and recording error incident reports may also be used. For example, if the organization uses paper incident reports, then the paper report can be received and the particulars recorded in the database 16. What is important is that the human error data is accessible for use in determining if one or more awareness factors predict human error in the organization 10. It will be appreciated that all data, whether related to error incidents psychosocial constructs or any other subject, should preferably be communicated to the database 16 as promptly as possible.
  • the data be entered through a web-based form for immediate uploading to the database.
  • the paper form be sent by a relatively fast method of transmission (e.g. fax) to a data entry point at which the data is entered into the database.
  • a relatively fast method of transmission e.g. fax
  • any method of recording data can be used which results in adequately fast entry of the data into the database 16.
  • the database 16 of the present invention automatically receives such automatically-recorded data in real time for use in data analysis.
  • the error incident data and psychosocial construct data are analysed (reference numeral 18) in association with one another to identify elevated risk of human error, and the cause of such elevated risk. For example, if, over time, a certain psychosocial construct or combination of constructs correlates with particular human errors, the organization can be notified of the causal connection, and provided with recommendation on how to prevent future errors that would otherwise take place if no action is taken.
  • the correlation between the psychosocial construct(s) and errors could take a number of forms. For example, the correlation could involve a change in both over time, or may involve lower levels of awareness in a specific section of the organization correlating with an unusually high number of certain types of errors in that specific section.
  • Data in the database are used to determine whether a risk of human error is indicated, and which awareness factors are causing the risk.
  • the presence and cause of a risk are preferably determined from analysing the psychosocial construct data, error data, and any other available data.
  • the Safety Officer of the organization is preferably notified (reference numeral 20) and informed of the type of error predicted by the data, and the cause as revealed by the psychosocial construct data. For example, suppose that an airport baggage handler has driven his vehicle into several baggage/cargo carts, damaging equipment, cargo and baggage. Meanwhile, data collected from baggage handlers shows that 37 percent of baggage handlers have begun reporting a lack of effective training in operational procedures, and 30 percent have begun saying that how they operate differs from standard operating procedure. The data in this case indicate that there will be additional human error resulting from lack of knowledge and understanding of operating procedures, a Functional Awareness problem.
  • the data may show that baggage handlers are well aware of operating procedures, and may be following those procedures, but that 43 percent of baggage handlers are not typically aware when they are in a fatigued state.
  • the Safety Officer would be notified that the data predict further error among baggage handlers caused by fatigue combined with a failure to be aware of the fatigue and take it into account.
  • This example demonstrates one of the main benefits of the present invention, namely, that the causes of errors are identified. As this example shows, a particular error could have one cause (e.g. fatigue) but if the cause is not identified, the organization may take action (e.g. more training) that will not be effective in preventing the error.
  • the prediction of error, and its cause can be communicated to the organization through some channel other than through the Safety Officer.
  • the Safety Officer is the preferred channel because of his dedication to safety issues and his channels of communication to those, such as the CEO, who can take action to prevent errors from occurring.
  • a Co. a corporate entity operating a business distributing food supplies to restaurants, caterers, foodservice companies and other similar entities.
  • a Co.'s operations include a number of tasks in which human error is a concern. For example, A Co. must order supplies, and receive and unload the ordered supplies.
  • a Co.'s employees receive orders from customers, and the orders must be picked and put together for shipping. The orders are then loaded for shipping and shipped to A Co.'s customers.
  • the present invention is deployed within A Co. to survey safety threats and other types of human error across the A Co. organization, and to identify the relationship between this human error and the levels of the nine types of psychosocial awareness described above.
  • the inventory of questions (reproduced below) is put to people throughout the organization (both management and labour - 850 employees in total) via online questionnaires.
  • the entire inventory of questions is put to the totality of company's people each month, with each employee answering only a subset of the full inventory each month.
  • the data collection takes place monthly over a period of three years.
  • the error prediction time period will be indefinite (i.e. continuing without any intended end point), so that the use of this error prevention method will form part of the normal operation of the organization.
  • the error prediction time period may be shorter.
  • the error prediction time period will be at least three years, though the invention comprehends shorter periods.
  • the steps of collecting and accessing data, and determining whether awareness factor data predicts human error can be done in a variety of different ways. Most preferably, the data collection and accessing, as well as the analysis used to determine if human error is predicted, are fully automated. In this preferred embodiment, human error data are accessible from or contained in database 16, and collected awareness factor data are contained in database 16. Statistical processes are automatically performed to determine whether there is prediction of human error. In the preferred embodiment, the following statistical processes known to those skilled in the art are used to assess the changing over the error prediction time period of human error frequency, type and severity, and of the psychosocial awareness factors: Longitudinal analysis for prediction/estimation: survival and hazard analysis, lag-regression (logit/logistic vs.
  • the types of errors that are typically made in our work environment are due to a lack of critical review of the safety status of our operational theatre 2.
  • the types of errors that are typically made in our work environment are due to individual team members not listening to critical opinion or challenge to existing operational conditions 3. In the last 3 months operational errors were made because of being exhausted and sleep deprived 4.
  • the types of errors that are typically made in our work environment are due to a lack of operational de-briefings of our individual and team performance
  • Management is solely responsible to disseminate any/all changes to our sops

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Abstract

L'invention concerne un procédé permettant d'empêcher une erreur humaine dans une organisation, le procédé consistant : à réaliser une pluralité de collectes de données de facteur de vigilance psychosociale sur une période de temps de prédiction d'erreur chez des individus exécutant des tâches à l'intérieur de l'organisation; à accéder à des données d'erreur humaine relatives à la période de temps de prédiction d'erreur sur des incidents dus à des erreurs humaines à l'intérieur de l'organisation; à utiliser les données d'erreur humaine et les données de facteur de vigilance psychosociale pour déterminer si le niveau d'un ou de plusieurs facteurs de vigilance prédit ou non une erreur humaine; si ledit ou lesdits facteurs de vigilance prédisent une erreur humaine, à avertir l'organisation de la nature de l'erreur humaine prédite, et du ou des facteurs de vigilance qui sont à l'origine de l'erreur humaine.
PCT/CA2008/000927 2007-05-11 2008-05-12 Procédé permettant d'évaluer et de communiquer un risque d'erreur humaine organisationnelle et ses causes WO2008138134A1 (fr)

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CA 2588347 CA2588347A1 (fr) 2007-05-11 2007-05-11 Methode d'evaluation et de communication de risque organisationnel d'erreur humaine
CA2,588,347 2007-05-11

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Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN110264028A (zh) * 2019-04-29 2019-09-20 中国电子科技集团公司电子科学研究院 一种装备体系贡献率评估方法及装置
US10783457B2 (en) 2017-05-26 2020-09-22 Alibaba Group Holding Limited Method for determining risk preference of user, information recommendation method, and apparatus

Families Citing this family (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
CN111027868A (zh) * 2019-12-13 2020-04-17 电子科技大学 基于结构方程模型的学位论文质量影响因素评价方法
CN110991924A (zh) * 2019-12-13 2020-04-10 电子科技大学 基于结构方程模型的高水平论文发表数量影响因素评价方法

Citations (1)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US20040256718A1 (en) * 2003-06-18 2004-12-23 Chandler Faith T. Human factors process failure modes and effects analysis (HF PFMEA) software tool

Patent Citations (1)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US20040256718A1 (en) * 2003-06-18 2004-12-23 Chandler Faith T. Human factors process failure modes and effects analysis (HF PFMEA) software tool

Cited By (2)

* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
US10783457B2 (en) 2017-05-26 2020-09-22 Alibaba Group Holding Limited Method for determining risk preference of user, information recommendation method, and apparatus
CN110264028A (zh) * 2019-04-29 2019-09-20 中国电子科技集团公司电子科学研究院 一种装备体系贡献率评估方法及装置

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