Sunday's THOUGHTFUL Post : HUMAN ERROR” IS NOT A ROOT CAUSE
Sunday's THOUGHTFUL Post ⚠️ “HUMAN ERROR” IS NOT A ROOT CAUSE An operator made a mistake. ❌ Investigation: “Human error. Retrain the operator.” 🔄 Problem solved? Not necessarily. If the same mistake can happen again, the root cause may still be in the system. 🔍 LOOK BEYOND THE OPERATOR Ask: 📋 Is the SOP unclear? 🖥️ Is the UX confusing? 🔄 Is the workflow too complicated? 🔢 Are there too many steps? 🚫 Is there no feedback or error-proofing? ⚙️ Is the process design flawed? 🧠 THE REAL QUESTION Don't ask: ❌ “Why did the operator make the mistake?” Ask: ✅ “Why did our system allow the mistake to happen?” 🛠️ BETTER ROOT-CAUSE THINKING Human Error → System Investigation → Root Cause → Corrective Action → Error-Proofing → Prevention 🎯 Training can be part of the solution. But retraining alone is often a band-aid, not a systemic corrective action. 💡 Design the process so that: ✔️ The right action is easy ✔️ The wrong action is difficult ✔️ Errors are detected early ✔️ Feedbac...