In my last article we discussed that all humans make mistakes, and we as managers need to understand why and then eliminate the chance of these mistakes happening again.Mistakes are made either inadvertently or deliberately.In this article we are going to examine why humans make mistakes inadvertently and what we can do about it.
Inadvertent mistakes are the ones we didn’t know about until it was too late.We didn’t follow a procedure because we didn’t know about it.We daydreamed while we should have been completing a task and got things wrong.We didn’t mean to make a mistake, it just happened.
These kinds of mistakes are the ones that when analysed, we tell ourselves that the person “is human” and they “just made a mistake”, so there is nothing we can do about it.However, this is wrong. We can, and we must, make it impossible for these mistakes to happen again.Companies who invest in understanding the reasons for human errors increase customer satisfaction, improve quality and make more profit.
As humans we all know that unlike a machine, which can repeat exactly the same task in the same way over and over, we are prone to mistakes or errors.We perform poorly if stressed, under pressure or through lack of concentration.As such we are fallible due to our physical, biological, mental and emotional characteristics, and to make it harder we are all different.Thus, we are susceptible to errors.
When people perform tasks in a complex work environment, then they are prone to slips, lapses and mistakes.Some people may get used to working with little sleep or in nosy environments, however when things are not as they normally are, that is when errors increase.Some key areas which affect all humans and make errors more likely include:
Stress or perceived stress can cause all kinds of issues, it causes panic, stopping people’s ability to recall, think or act.It leads to anxiety and fear which can be followed by memory lapses, the inability to think critically or perform physical acts with accuracy.The stress may be at work or at home but the outcome will be the same.
Mental strain also causes issues.We as humans don’t like engaging in long periods of concentration as it requires high levels of attention and great effort.If you have ever been on a training course and can’t understand why you are so tired at the end of day this is why.As mental strain increases, we start to accept OK levels of quality or output as anything more is too hard.
We all have a limited number of items we can hold in short term memory.Most people can only hold between 5 to 8 items at a time.This means that our short-term memory is at the root of forgetfulness, this leads to tasks not being well performed of forgotten about all together.How many things do you have on your mind at any one time?How often do you forget to do things as there are so many to think about?
We also have a limited number of items we can concentrate on at one time typically 2 or 3.We only have so much attention we can give tasks, if that attention is drawn onto one item, the others will be affected.The item we think is the most important, will be the one we concentrate on.If this is not the key item at hand, then we will slip, lapse or make a mistake.If we forget a partner’s birthday, and begin to think getting them a gift, that will take all of our focus. Our chances of mistakes at work are now higher than normal.
If we have the wrong mind-set, we make mistakes.People tend to focus on what they want to accomplish e.g. producing 200 units a day.The result is that we focus on our goal rather than looking for issues that need to be avoided to complete the task.We will miss conditions or circ*mstances which we don’t expect as we are used to the patterns we normally see in order to complete our goal.For example, we might miss that the quality of our raw materials is getting worse over time as we just want the 200 units produced.We need to make it clear what needs to be avoided as well as what needs to be accomplished in a task.
It is also difficult to see your own errors, which is why self-checking is not always the most effective way to stop errors.How many times have you written something and when somebody else checks it you have missed an obvious error?
Emotions, anger, sadness, happiness and embarrassment will affect anyone’s performance, as will fatigue through lack of sleep. If you have ever had children, you know your chances of making mistakes are increased due to the lack of sleep.Forgot to turn the washing machine on, where you left things, why you went into a room.
Humans also continue to complete tasks even when they are not at their optimum level, and may even be aware of this.People come to work when they are sick or have other health issues.If you have a backlog of work or any impairments, then this will also make you less than optimal.These elements can easily lead to human errors.
We must understand why people make mistakes so we can analyse them and do something about them.We can split inadvertent errors into 3 categories
- Slips – not doing what you were meant to do
- Lapses – forgetting to do something, or losing your place midway through a task, lack of concentration
- Mistakes – misinterpretations or lack of knowledge which occur when we do the wrong thing, believing it to be right - Rule based mistakes or Knowledge-based mistakes
Slips and lapses occur in very familiar tasks which we can carry out without much conscious attention, e.g. driving a vehicle. These tasks are very vulnerable to slips and lapses when our attention is diverted even for a moment.
When might we make a slip or a lapse?Typically, when the task is very familiar to us so we don’t give it much thought.The task we are doing is boring or long winded to complete we drift away in our minds and ‘whoops’ we have an error.It could happen when there is noise or distractions around us while trying to work.If we are constantly interrupted by phone and emails, and then go back to a task we may slip.We might have two similar tasks, such as putting numbers on a spreadsheet and confuse the two tasks.It could be that the flow of a procedure is overly complicated and we miss one as a result.Or perhaps we are good at the high-level detail but slip when it comes to the finer detail.
We are all liable to slips and lapses in concentration.Some examples might include:
- Filling the kettle but forgetting to turn it on
- Not putting on safety equipment before starting a task
- Placing the wrong number in the wrong column on a spreadsheet
- Picking the wrong bolt for a job as they are hard to tell apart
- Reading a dial wrong or recording the data incorrectly
- Picking the wrong job sheet
Training will not solve these issues.We need to think about ways to eliminate these kinds of slips and lapses.The aviation industry work on these areas constantly to keep flying as the safest form of transport.You can follow their lead by doing things such as:
- Ensure everyone is aware slips and lapses happen so it’s not a shock – don’t blame, find ways to eliminate them or their consequences
- Incorporate checklists which are checked by two people
- Ensure all procedures are simple, logical and easy to follow
- Start procedures by how to lay things out to remove issues
- Find ways to remove distractions – no calls
The other category of inadvertent human errors are mistakes.This is where a person thinks they are doing the correct thing but they are not.This is not a deliberate mistake it’s a consequence of lack of understanding.
Typically, these kind of mistakes occur when we are working on too many things at once.We forget to include an attachment when completing a sales proposal as we have 10 other proposals to do at the same time.Time pressure is also a major contributing factor to this kind of error as is working on lots of complicated items at once.Something is going to give, and errors are formed.
Examples of these kinds of mistakes include:
- Making a bad judgement when overtaking
- Not hearing an alarm on a machine as you are concentrating on something else
- Missing a deadline as you have too many all at once
What are the factors which therefore make us prone to mistakes of this kind?
- The environment we work in – too hot, too cold, poor lighting, restricted workspace, noise
- Completing extreme tasks – high workloads, boring and repetitive jobs, jobs that require a lot of concentration, too many distractions
- Social issues – peer pressure, conflicting attitudes to health and safety, conflicting attitudes of workers on how to complete work, too few workers.
- Individual stressors – drugs and alcohol, lack of sleep, family problems, ill health
- Equipment problems – inaccurate or confusing instructions and procedures
- Organisational issues – failing to understand where mistakes can occur and implement controls, such as training and monitoring
How can we reduce mistakes?
- Increase people awareness of which tasks are high risk to increase concentration levels
- Develop procedures for non-routine high-risk tasks
- Ensure all inexperienced staff are properly supervised
- Use job aids, diagrams, pictures to demonstrate procedures
- Provide eLearning for procedures so people can get quick recaps on how to complete tasks
As humans, our very make up makes us prone to inadvertent mistakes.As managers, or people looking to eliminate errors, we need to understand why slips, lapses and mistakes happen.We can then design our processes, procedures, systems and management to reduce them, or even better, eliminate them all together.This takes a change approach to problem solving and also to identifying true root cause of an issue.
100% Effective Ltd support clients to understand and eliminate root causes of human mistakes or errors.Please get in touch with me to discuss how we can help you in your business.
In part 3 we will look at deliberate mistakes or violations.Review Part 1
