Preventing human error

11 July 2019

The latest version of ISO 9001 included many significant changes, and the headline acts were probably the change in focus from documentation to risk management, the enhanced process requirements, and the adoption of ISO's common structure and terminology.

However, there were a few requirements that slid in without much fuss and fanfare. One of them is in clause 8.5.1 Control of production and service provision. A controlled condition that appeared for the first time is 'the implementation of actions to prevent human error'. What is human error? Well, we might define it as when someone makes a mistake or causes something bad / unwanted to occur. In the quality management context, that error may lead to a process or system exceeding its acceptable limits.

We would suggest that the consideration is extended slightly to become 'errors and omissions' - for people are just as likely to forget to do something, as they are to do it wrong.

The term 'Poka-Yoke' might sound like an exotic ice cream, but is in fact a Japanese term meaning 'to avoid careless mistakes' (You may have noticed that many quality management terms and concepts have a Japanese history). A Poka-Yoke is a method or device that eliminates product defects by preventing, correcting, or at least drawing attention to human errors when they occur. The concept of Poka-Yoke is widely utilized in Lean manufacturing.

One example of error-proofing that is often quoted is the story of the empty cardboard boxes on the production line. The example is based in a manufacturing plant where packers put items into cardboard boxes as they move along a conveyor belt. The story goes that every now then a box is missed, and travels on to be sealed up even though it is empty. The problem was how to prevent that? The solution that someone came up with was to put a pedestal fan at a suitable location on the side of the conveyor belt. It wouldn't affect full boxes but would simply blow an empty box off the belt. We are not sure about how true the story might be, but it does illustrate the concept of error-proofing, and how an inexpensive device can prevent an error from going any further.

At this point, some of you may be thinking 'that's great, but we don't do manufacturing'. The reality is that these days most of us are engaged in service industries of some kind or other. So, the question is how to apply error-proofing in service industries? We provide some examples below.

One of the key things that sets service industries apart from production industries is the interaction with customers or clients. Therefore, while some of the suggestions below relate to processes within the service provider organization, some address the interaction with the customer, and their perception of the service:

  • Documenting processes in a clear and easy-to-follow manner e.g. if you are sawing a branch off a tree, ensure that you are not sitting on the thinner side of it.
  • To-do lists or task lists.
  • Clear visual indications such as different coloured folders or storage areas folders for different records or items.
  • Peer reviews.
  • Standardising appearance - worker's uniforms, vehicles, premises etc. to give confidence.
  • Standardising how workers interact with customers - template documents, emails, telephone scripts, and training.
  • Automated emails or SMS to customers to remind them of appointments, and for confirmation by response.
  • Automated emails to immediately respond to enquiries etc.
  • Automated logging and forwarding of enquiries etc.
  • Checklists to breakdown complex tasks into bite-size chunks of what should happen. The usefulness of checklists is enhanced with features such as conditional formatting in Microsoft Excel, where incomplete or late items may be visually very apparent.
  • Software. Rules within software design may prevent tasks from being closed until all required steps have been taken. As an example, our Qudos 3 software will not allow an Action to be closed until all mandatory sections are complete and locked. It will also periodically remind people about incomplete audits, actions, and other tasks until they have signed off on them.
  • AI (Artificial Intelligence) can remove the human element in whole or part from some tasks.
  • Continuous improvement elements of a QMS can help to ensure that if an error does occur once, steps are taken to prevent it from happening again.

These are just a small selection of possible methods in service industries to prevent error or dissatisfaction. Hopefully, they are enough to fire your imagination.

The above is based on an article in Quality Manager Toolkit – available in Qudos 3 software and QudosClub online resource centre.

P.S: We deliberately included a typo in the above - did you spot it? (and we don't mean the Anglo-English spellings such as 'coloured'). Its the double use of the word folders in the 3rd bullet points (if you spotted 2 typos - that was a human error!)