October 1, 2005 | Mark Paradies

Mistake Proofing & Root Cause Analysis

If you don’t know much about mistake proofing, I’d start to learn something by seeing John Grout’s web page. He has many easy to understand examples that easily demonstrate the concept of mistake proofing (the example below comes from page six of John’s examples).

Sometimes mistake proofing is seen as a discipline completely outside the realm of root cause analysis. But I see them as closely aligned and very complimentary.


How are they related?

First, and most obvious, is that mistake proofing can be used as an effective corrective action for many types of simple human errors. In PhD terminology these types of errors are called “slips” and “lapses”. This is the topic of John’s talk at the 2006 TapRooT(R) Summit in Gatlinburg, Tennessee, on April 5-8. His talk is part of the Breakout Sessions in the Quality Improvement Best Practices and the Human Performance & Behavior Change Best Practices Tracks.

Second, lack of mistake proofing can be a cause behind Human Engineering causes including Controls Need Improvement and Displays Need Improvement that are part of the TapRooT(R) Root Cause Tree(R).

The fact that poor displays and controls can lead to slips and lapses shows a partial view of how the TapRooT(R) Model of error causes includes the theories of James Reason’s models of Slips, Lapses, and Latent Errors that I will be presenting to the General Session of the Summit on Thursday morning.

If ways to prevent common human errors is one of your concerns (an area you would like to improve), then you should consider attending the TapRooT(R) Summit. I’m sure that you won’t be disappointed by the lessons that you will learn.

Root Cause Analysis
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