MODULE 1

Error Prevention Basics

BASIC TOOLS FOR REDUCING MISTAKES

Introduction to the EP Handbook

Do you know anyone who gets up in the morning, looks out the window and says “What a great day to make a mistake!”? Of course not! So why do people make mistakes? Why is it so hard to eliminate accidents?

 

The answer is that there are traps of human nature that lead us to make mistakes when we least expect it. We call them traps because we don’t realize when they are working – if we did, we wouldn’t make nearly as many mistakes or have as many accidents.

 

This online guide will identify these traps, help you to recognize when they are working, and provide you with practical, easy-to-use tools to avoid or deal with these traps.

Quick tip: Traps are listed throughout the Handbook in red and Tools appear in blue.

Definitions

PIC- Person In Charge
Usually in any situation someone is in charge. This person may not actually have a specific title, or may be referred to as supervisor, team leader, manager, director, chief, captain, etc. In our seminar, PIC is a generic term to indicate the person or persons in charge.

Team

Any group of two or more people working on a common project or task, even though they may not necessarily always be called a team.

Trap

A weakness inherent in human nature that reduces our effectiveness and can lead us to take actions contrary to policy, procedures and simple common sense - putting people, equipment and projects at risk.

Tool

A simple, practical method used in Error Prevention to detect and avoid or deal with one or more Traps.

We all make mistakes...Balancing Risk and Safety

Risk Assessment

Risk assessment is inherent in the decision-making process. Unfortunately, people may not be aware of all the risks involved in a particular decision, or they may tend to minimize risks, especially risks they deal with every day.

TOOL

TOOL

Standard Operating Procedures (SOP)

These are specific written instructions on how to do all phases of our jobs, and how to handle anticipated critical situations. A good SOP can help overcome the temptation to operate in an unwise manner, whether it is coming from ourselves or others. Even someone in a one person department can benefit from putting specific operating procedures they intend to follow down on paper. The Traps and Tools™ you are learning about in this seminar should be in your SOP.

TOOL

TOOL

TOOL

PINCH

If the PIC has not succeeded in establishing a comfortable atmosphere of open participation, other team members may not verbally communicate their feelings. However, they will still communicate their feelings nonverbally. When we sense that someone is upset about something, we call that a "pinch." It is important to "address the pinch" as soon as you are aware of it. If this is not done, the pinch may grow into a disruption. While it is possible to resolve a disruption, it is much easier to handle at the pinch stage.

TOOL

TOOL

TOOL

AESOP

The AESOP™ Model is very effective as a mind-jogger to ensure that important factors are not inadvertently overlooked. Use AESOP™ at each stage of planning or completing a task to make sure you take into account each factor.

image-aesop.png

TOOL

TOOL

TOOL

Conservative Response Rule

One thing the PIC can do to encourage feedback and open discussion of problems and concerns is to institute the Conservative Response Rule™, which dictates a conservative response to any ambiguity.

TM