Improvement Insights Blog
Human Error and System Design
All too often I hear people say: “It’s just human error.” No it’s not. Here’s why:
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“Hi, I’m Jay Arthur, author of “Lean Six Sigma For Hospitals” and QI Macros [software].
“I was talking to somebody the other day, and we were talking about things in general, and they said, “Well, you know, it’s just human error.” And I said, no, stop. There’s no such thing as human error.
“Now, I know that’s a limiting sort of thought, but I believe that systems let people make mistakes. And if you get the systems right, people can’t make those mistakes anymore.
“My car won’t let me forget that I’m coming up too fast on another car that’s stopped in the middle of the road, and it’ll start beeping at me, and if I don’t do anything, it’ll slam on the brakes. Do you get this idea?
“In 1999, the Institute of Medicine (IOM) had [a book] “To Err Is Human”. No, it’s not. It’s systems error. They let people make mistakes. Any time you hear somebody say, “Oh, it’s just human error,” you can stop them right there and say they’re just too lazy to sit down and figure out how the system let them make that error.
“So, that’s my Improvement Insight. Let’s go out and improve something this week, like one of the systems that is letting people make stupid mistakes. Let’s have some fun out there.”
