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Marilyn Sue Bogner, Ph.D., founder of the Institute for the Study of Human Error, LLC in 1995, consults on a variety of error-related issues and incidents, conducts research related to and in applied settings, investigates accidents and provides expert testimony. In this interview, Bogner discusses the Artichoke systems approach to understanding the nature and dynamics of error in the workplace and the value of that approach and associated tools for addressing human error.

Please provide a brief overview of the Institute for the Study of Human Error, LLC.

Although the work of the Institute for the Study of Human Error, LLC (ISHE) primarily addresses human error in health care, the approach is applicable to all industries.

The basis for the ISHE systems approach is the consideration of error as behavior. This has a profound impact on efforts to reduce error because behavior is not instigated solely by a person. Behavior (B) is a function (f) of the person (P) interacting (x) with factors in the environment (E), B = F{P x E}. This is attested to by theory and research not only in psychology and the other social sciences, but also in physics, chemistry and all of the physical sciences. Because behavior involves factors in the environmental context as well as the person both of those components must be addressed when considering error. In the ISHE approach, the environmental context is comprised of interacting categories of factors that were consistently identified across error-related studies conducted by a variety of industries.

The ISHE systems approach operationally defines the term “system” as the environment in which a person behaves performing a task, which is expressed as eight evidence-based hierarchal categories of interacting factors which affect the worker. The system is represented as an artichoke with the concentric circles of leaves representing the categories of factors; the worker is the heart of the artichoke. This appears as the ISHE logo.  

The Artichoke systems approach consists of five steps. The first is to determine the context in which the behavior that was considered an error occurred. The second involves identifying the factors associated with the error, including precursor events by considering the error behavior guided by the Artichoke worksheet. In the third step, the targets for remediation are determined by applying the 5 Why technique to each of the identified factors and precursor events with the technique being continued until an actionable item is identified for each of the factors. The fourth step implements the remediation of those identified aspects of factors and events that contributed to error. The fifth step is the evaluation of the effectiveness of those activities.

Despite advances in safety, health and environmental management (SH&E), occupational injuries and accidents continue to occur. How would the systems approach address the role human error plays in injuries and accidents?

That injuries and accidents persist despite advances in SH&E management indicates that the advances have not addressed the actual causes of the accidents that resulted in the injuries. The most common reason for this is people tend to respond to the injury end point of an accident and presume the cause was human error. The Artichoke systems approach can be applied to analyze an accident to determine the factors that contribute to what is considered human error. This would most effectively be done initially by the person most knowledgeable about what occurred in the accident—the person who appears to have caused it. That person would follow the steps of the Artichoke systems approach to identify precursor events and other factors that contributed to the behavior that caused the accident using the Artichoke worksheet tool to ensure each aspect of the contextual system was considered.

The worker then analyzes each factor using the 5 Why technique until an actionable item is identified. There is an ever-present temptation to avoid the systems approach analysis and presume a probable reason the incident occurred and implement some corrective action. That temptation, although understandable because it is expedient, must be resisted and the incident carefully defined and systematically analyzed to determine why the incident occurred and to identify what factor(s)induced the error. Without that information, the effectiveness of activities implemented to address an incident is compromised.
What is the primary cause of this human error? Do specific circumstances increase the chance of human error in the workplace?

The primary cause of human error and accidents in the workplace is conditions and factors in the work environment—factors that are inappropriate for the skills, knowledge, abilities and the physical as well as cognitive characteristics of the worker. Specific circumstances that increase the likelihood of human error are those demonstrated to adversely affect human performance whatever the situation, such as inadequate illumination, equipment that is inappropriate for the worker’s information processing and anthropomorphic characteristics of physical height, reach and grasp as well as non-intuitive operation of equipment and shift rotation that disrupts the worker’s circadian rhythm—factors that are considered in a human factors approach.

Effective SH&E management systems can help prevent workplace injuries and accidents. Does any evidence suggest that SH&E management systems that do not meet certain criteria might actually increase human error?

Management systems that do not meet the criteria of addressing both components of error behavior increase error. Considering only the worker in addressing error-related issues discourages discussion of error for fear of being blamed for it. Blame puts workers in embarrassing and punitive circumstances so they tend to hide errors whenever possible. Workers also will tolerate potentially error-provoking factors by working around them as best they can. This establishes conditions for errors to occur, which will continue and increase with the introduction of new employees and changes in the work environment.

To be truly effective, management programs must change their focus from who committed an error to why the error occurred. This can be accomplished not by managing employees but by empowering them to exercise their unique ability to identify workplace factors that can and do cause error. This makes workers partners in safety rather than targets for blame. This not only contributes to developing a safety culture, it also enhances the safety of the workplace. It will, however, take considerable effort on the part of management because of the power of contextual factors that is similar to that in James Bond movies.

In the movies, James Bond always gets the girl whether he is played by Sean Connery or Roger Moore because the script—the props, the other people and factors in the context as well as the time sequence—establishes the conditions that lead to James getting the girl, which is a situation that can be very frustrating to other men and frustration is well documented as leading to errors. To change the outcome so James Bond does not get the girl, it is necessary to change the script.

In a work situation, conditions that induce specific behaviors, such as drug names that are the same except for one letter, increase the likelihood of error of administering the wrong drug. This does not change regardless of the nurse administering the drug because of the human tendency to perceive very similar objects as the same. Chastising the nurse and sending him or her to training will not alter the conditions of similar names that lead to the confusion. This is an example of the James Bond script syndrome and the errors will continue until the script of such similar drug names is changed. Thus, efforts to reduce error directed only to the individual involved, the worker, are misdirected. Because of this they are not effective in identifying the actual issue and determining its cause, which allows the James Bond script syndrome to prevail, making a bad situation worse by increasing the incidence of error.

How can the concept of prevention through design help control human error in the workplace?

Prevention through design decreases the likelihood of error by developing equipment, procedures and information appropriate for safe and effective task performance by workers. This involves a human factors/ergonomics approach of designing the work environment from the users’ perspective. This design is appropriate for workers’ physical and cognitive abilities as well as human characteristics, which have been found to contribute to errors: lack of tolerance of loud noises, handedness and forgetting to turn on silenced alarms.
The focus for error prevention must be on design because it is factors in the workplace, which affect the workers—factors that comprise the script for the performance of the worker—the James Bond script syndrome described previously. Inappropriate design of such factors cannot be overcome by training because the error trigger is in the design. Even if training were effective, it impacts only those who receive it—not new employees and not those who are unavailable for training.

To control and reduce human error, ergonomic design should be applied to factors in the context of work typically not considered as error-related but are such as information presentation, procedures, work schedules and the placement of objects in a work space, as well as the machinery and other pieces of equipment involved in work. In short, all aspects of the work environment should be designed to be appropriate for the workers’ skills, characteristics, abilities and human nature. This not only reduces the likelihood of error and accidents, it also enhances task performance.

How can SH&E professionals convince workers of the need to reduce human error without appearing to place blame on anyone?

Convincing workers of the need to reduce error without appearing to blame anyone is simply to focus on the actual causes of error, which are workplace factors that precipitate error by affecting the worker and precursor events that set the stage for the response to those factors. This involves considering error as what it is—behavior. This spreads the focus in addressing error from being solely on the person to factors in the workplace that impact the worker hence there is no person to blame. Workers are in the unique position to identify factors that can cause errors and accidents—errors waiting to happen, hazards. Thus, workers can play a central role in developing a safety culture. By considering the contribution to error by workplace factors represented by the Artichoke rather than the person, the worker’s concern about blame can be transformed into that for making the workplace safer.
Based on your experience, what approaches work best for reducing human error and subsequent injuries and accidents? How do you measure the success of these approaches (month to month, year to year, etc.)?

In my opinion, the best approach is to involve workers in identifying factors they know induce errors and accidents so those factors can be removed or changed in accordance with human factors/ergonomic considerations. It is important that the workers do this because they experience the working conditions and can identify what affects them. The success of this approach can be measured by the extent of effective remediation of factors identified by the workers as contributing to an error—the measure being in terms of reducing or ideally preventing recurrence of the error. When such effective remediation occurs, the value of the approach is multiplied by implementing the changes in comparable conditions throughout the company.

Should there be uncertainty about the worker’s conclusions regarding an error, the incident can be analyzed by a co-worker who observed it using the steps of the Artichoke model. This should occur as a collaborative activity to avoid the connotation of blame. Because employees tend to work around problems, become accustomed to them and may not recognize them as problems, a person from outside the company might be consulted for identification of general safety issues. To minimize the employees’ concern about being “checked up on” and blamed for problems by such a consultant, which could lead hiding safety concerns, employees should be informed of consultant involvement and the purpose of that involvement discussed. A side benefit of worker involvement and a collaborative nonjudgmental approach is increased job satisfaction and company loyalty, also measures of success of the approach albeit indirect measures.   

Based on current workplace injury/accident data and statistics, which industries do you believe might benefit the most from strategies to reduce human error?

Health care directly affects the lives of people so errors in health care-related industries, such as manufacturing medical devices and laboratory equipment, that affect product quality are more likely to have catastrophic consequences than in other industries. Because of that, the health care industry might benefit most from efforts to reduce human error. Efforts to reduce human error should be ongoing throughout any industry by vigilance in identifying and effectively addressing workplace factors that induce error. For this to be successful there must be support and involvement from high-level management.
Despite the undisputed importance of reducing error, strategies persist that have been found to be ineffective in addressing error, strategies that focus solely on the worker as the cause of error. The incidence of errors will continue and will likely increase with the introduction of more sophisticated technology until the search for the cause of error is expanded from who committed the error to why it occurred and ultimately to what factor(s) induced the error and how those factors were effectively rectified.

How can companies best incorporate strategies to reduce human error into their risk management/loss control programs?

Companies can develop and launch an employee-based strategy to identify and rectify error-inducing factors in the context in which they work. This will take commitment on management’s part to establish an administrative point of contact empowered to address employee-identified, error-inducing factors. This might reside in the risk management domain, but it should be a discrete employee-based endeavor.

Multiple successes in reducing error and accidents occurred in health care facilities that applied the lean approach distilled from the total quality improvement approach that changed Toyota from a floundering industry into the giant it became before success compromised quality. The effectiveness of such an approach comes from being employee-driven and likely would be compromised when adopted by an industry if it were incorporated into an existing program that is not completely focused on that approach. The payoff from the approach to reducing and preventing errors by identifying and rectifying error-inducing factors in the work environment is too promising not to try.

Marilyn Sue Bogner, Ph.D., is a consultant active in conducting research, investigating incidents and providing expert testimony on human error issues. Her professional background includes teaching at Catholic University of America and advising the design of the turret of a self-propelled Howitzer for the Army Research Institute from which she was recruited by the Food and Drug Administration to investigate the contribution of medical device design to error. Currently, she conducts patient safety workshops in the U.S., Europe and the Middle East on the application of her systems approach to preventing various types of medical error.

She has been interviewed on medical error issues for National Public Radio distribution and participated in as well as directed Continuing Medical Education videos. She has published well over 80 articles, has made more than 150 presentations at professional meetings both in the U.S. and abroad, has contributed chapters to 15 books and has published two edited books: Human Error in Medicine (1994)and Misadventures in Health Care: Inside Stories (2004). The 2nd Edition of Human Error in Medicine will be published by Taylor & Francis in 2011. She edited a patient safety column in Biomedical Instrumentation and Technology published by the American Association for the Advancement of Medical Instrumentation from 2003 to 2007 and edited a special section of the journal Human Factors on Medical Error.

She is a peer reviewer for 12 journals, including the Journal of the American Medical Association and Applied Ergonomics and is on the editorial board for the journal, Safety Science. Bogner is a Fellow of the American Psychological Association, the Human Factors and Ergonomics Society and the Washington Academy of Sciences. She holds a B.S. in Psychology and Mathematics and a Ph.D. in Psychology (Gestalt).