Cognitive Lapses and Safety Flashcards
human factors and thinking
- avoid reliance on memory
- make things visible
- review and simplify processes
- standardize common processes and procedures
- routinely use checklists
- decrease the reliance on vigilance
human factors
*study of ALL factors that make it easier to do work in the right way:
1) cognitive ergonomics (individuals at work)
2) physical ergonomics (task at hand)
3) organizational ergonomics (workplace)
designing for human factors:
1) is about designing systems that are resilient to unanticipated events
2) addresses problems by modifying the design of the system to better aid people
3) ranges from individual to the organizational level
4) DECREASES THE LIKELIHOOD OF AN ERROR OCCURRING
what is an error
1) failure of a planned action to achieve its intended outcome
2) deviation between what was actually done and what should have been done
situations with an increased risk of error
-unfamiliarity with task
-inexperience
-shortage of time
-inadequate checking
-poor procedures
-poor human equipment interface
area of optimum stress
performance level is best when at a balance between low stress (boredom) and high stress (anxiety)
how humans make errors
1) skill-based errors
2) rule-based errors
3) knowledge-based errors
skill-based performance
routine, frequent tasks in a familiar environment that you can do without even thinking about it (like you’re on auto-pilot)
errors associated with skill-based performance
1) slip - without intending to, select incorrect action
2) lapse - without intending to, fail to do intended action
3) fumble - without intending to, mishandle or blunder action
prevention strategy for errors associated with skill-based performance
stop and think before acting
process-improvement strategies for errors associated with skill-based performance
-automation
-interruption reduction
-self or second-person checks
-visual cues, reminders
-checklists
-device design
rule-based performance
responding to situations by recalling and using rules learned either through education or experience
errors associated with rule-based performance
1) used the wrong rule - taught or learned incorrect response for situation
2) misapplied a rule - knew correct response but picked another instead
3) non-compliance - actively choose not to follow rule
prevention strategies for errors associated with rule-based performance
-educate about correct rules
-think a second time
-reduce burden, increase risk awareness, improve coaching
process-improvement strategies for errors associated with rule-based performance
-procedure correction, standardization, details, and clarifications
-educate on rules
-procedure detail and clarity
-task simplification
-intuitive work environmnet
-component design, task location or workflow adjustment
-consequence education (low-risk)
-Code of Conduct (high-risk)
