Mistakes and omissions, and how to prevent/reduce
Discussion
Speaking as a person who is inclined to make mistakes and forget to do stuff, this is a subject that fascinates me. After making an annoying mistake at work yesterday I looked into the subject on YouTube and found there was great deal of material on this subject.
Maybe that was what I was thinking about when I closed up the workshop at the end of the day and forgot to set the heater to come on in the morning so as to warm the place up before I get there!
This morning I looked through my checklist before coming to work and nevertheless came away without one of the items on the list (trivial but irritating).
The consensus of the various lectures I listened to yesterday on YouTube was that mistakes can't actually be prevented, they can only be reduced. Anyone have any thoughts on that, or this subject in general?
Maybe that was what I was thinking about when I closed up the workshop at the end of the day and forgot to set the heater to come on in the morning so as to warm the place up before I get there!
This morning I looked through my checklist before coming to work and nevertheless came away without one of the items on the list (trivial but irritating).
The consensus of the various lectures I listened to yesterday on YouTube was that mistakes can't actually be prevented, they can only be reduced. Anyone have any thoughts on that, or this subject in general?
Interesting. Check lists are good but obviously can only relate to expected aspects, I’ve gone back into flying and every aspect from pre flight, post take off, pre landing and shut off is all done with a check list. As you’ve found they also only work if followed.
A friend was quite senior at the CIA and was an expert in chaos theory ( https://en.m.wikipedia.org/wiki/Chaos_theory ) and basically said that no matter how much you prepared for things something else will always happen.
A friend was quite senior at the CIA and was an expert in chaos theory ( https://en.m.wikipedia.org/wiki/Chaos_theory ) and basically said that no matter how much you prepared for things something else will always happen.
Given the very expensive outcomes of a simple and easy to miss mistake in my work we have quite a formal process around examining how they were made.
It’s done without blame, and involves looking at how the mistake happened, why the current processes didn’t stop it, and what changes are needed to make it far less likely to happen in the future.
It doesn’t have to be complex or onerous; one good example is that every trader should have a physical “blotter”, and the first thing that they do after executing a trade is to note it in there.
If done every time it means that we know for certain if a deal was done or not, and at what price.
In your example with the heater, a solution could be that your keys. Which you need in order to lock up, are hung next to the heater control, and when you go to pick them up you know that you hit the timer button first.
It’s done without blame, and involves looking at how the mistake happened, why the current processes didn’t stop it, and what changes are needed to make it far less likely to happen in the future.
It doesn’t have to be complex or onerous; one good example is that every trader should have a physical “blotter”, and the first thing that they do after executing a trade is to note it in there.
If done every time it means that we know for certain if a deal was done or not, and at what price.
In your example with the heater, a solution could be that your keys. Which you need in order to lock up, are hung next to the heater control, and when you go to pick them up you know that you hit the timer button first.
Checklists / routines work for me and my staff, but it does of course depend on the context.
I try to make things idiot proof, although this is not always possible when you don't have control, for example when using third party systems or software that have poor workflows and are not idiot proof, but we have to use them.
One problem I have in my business is that I only trust myself with high risk tasks, such as importing/exporting data between systems because the stakes are just too high if someone cocks up in excel, or forgets to format columns in a specific manner required by the software systems we use.
I've had it in the past where an employee had overwritten hundreds of records through carelessness in excel, and it took days to recover.
I suppose one solution would be to change systems, but the time/effort does not justify the retraining alone, and I often find these days that software companies promise the earth but after implementation and £0000's, things don't always work as they were sold and it turns out your new software is OK at something your old software was not good at, but absolutely crap at something your old software was fantastically good at and they spend more money on UI and pretty buttons and layouts than development .
I try to make things idiot proof, although this is not always possible when you don't have control, for example when using third party systems or software that have poor workflows and are not idiot proof, but we have to use them.
One problem I have in my business is that I only trust myself with high risk tasks, such as importing/exporting data between systems because the stakes are just too high if someone cocks up in excel, or forgets to format columns in a specific manner required by the software systems we use.
I've had it in the past where an employee had overwritten hundreds of records through carelessness in excel, and it took days to recover.
I suppose one solution would be to change systems, but the time/effort does not justify the retraining alone, and I often find these days that software companies promise the earth but after implementation and £0000's, things don't always work as they were sold and it turns out your new software is OK at something your old software was not good at, but absolutely crap at something your old software was fantastically good at and they spend more money on UI and pretty buttons and layouts than development .
It’s in incredibly interesting area of business (especially if you’re a bit OCD).
Check lists and work instructions/procedures are great tools of there’s clear task definition. Throw in some decision trees and you can also accommodate variations… but new things can and will go wrong. Reducing defect rate tends to require constant learning (and a culture that doesn’t involve sweeping things under the carpet - as NB says, blame the process not the person!).
The really simple but neat stuff comes in manufacturing process where you start looking at poka yoke (mistake proofing) and design things such that it is impossible for certain errors to occur. For example, one square pin and one round pin on an otherwise symmetrical fitting, or physical gates on production lines to only allow correctly dimensioned parts through.
Of course you can throw a lot of analysis time and tools at problem solving. Where people tend to struggle is unpicking cause and effect, personally I like 5-why as a simple to explain approach that really helps get to the root of many errors. Whether you then solve for the various underlying issues needs an understanding of the cost/complexity/benefits vs, ideally, some evaluation of probability/impact.
If it’s an area you’re interested in then I’d highly recommend reading some 6-sigma books. If you want any suggested books then let me know and I’ll jot some down. Spending time to understand process is rarely wasted, and can have real impact across businesses of all sizes.
Check lists and work instructions/procedures are great tools of there’s clear task definition. Throw in some decision trees and you can also accommodate variations… but new things can and will go wrong. Reducing defect rate tends to require constant learning (and a culture that doesn’t involve sweeping things under the carpet - as NB says, blame the process not the person!).
The really simple but neat stuff comes in manufacturing process where you start looking at poka yoke (mistake proofing) and design things such that it is impossible for certain errors to occur. For example, one square pin and one round pin on an otherwise symmetrical fitting, or physical gates on production lines to only allow correctly dimensioned parts through.
Of course you can throw a lot of analysis time and tools at problem solving. Where people tend to struggle is unpicking cause and effect, personally I like 5-why as a simple to explain approach that really helps get to the root of many errors. Whether you then solve for the various underlying issues needs an understanding of the cost/complexity/benefits vs, ideally, some evaluation of probability/impact.
If it’s an area you’re interested in then I’d highly recommend reading some 6-sigma books. If you want any suggested books then let me know and I’ll jot some down. Spending time to understand process is rarely wasted, and can have real impact across businesses of all sizes.
All good stuff above. Check lists for defined tasks are a winner.
A related discipline I try and follow is deliberately not to remember anything. Any to-do item is written down, direct on my phone or could be a post-it, piece of paper, anything, which can be put on the phone later. Then you know - there's one list, it's got everything on it, you haven't forgotten anything, you can leave stuff there and come back to it later.
A related discipline I try and follow is deliberately not to remember anything. Any to-do item is written down, direct on my phone or could be a post-it, piece of paper, anything, which can be put on the phone later. Then you know - there's one list, it's got everything on it, you haven't forgotten anything, you can leave stuff there and come back to it later.
Newc said:
Any to-do item is written down, direct on my phone or could be a post-it, piece of paper, anything, which can be put on the phone later. Then you know - there's one list, it's got everything on it, you haven't forgotten anything, you can leave stuff there and come back to it later.
Yep. I swear by an A5 diary on the desk, and a small pad of paper and a pencil in the bedside drawer for those random but brilliant extra things that float into your mind in the small hours.Gassing Station | Business | Top of Page | What's New | My Stuff