In addition to the recording of errors, an awareness of possible errors and the corresponding damage limitation must also be created. You can find out how to do this here.
- immediate measures
- Everyone has to think along
- root cause analysis
- Possible causes of errors by employees are
- Several causes interlock
- Difference to scapegoat culture
- 5 “why” questions
- Checklist for causes research
- Quality and risk management
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immediate measures
The following important Ask everyone should Employees in the event of an error, set immediately:
- Who needs to be informed?
- What time window do we have?
- Which strategies are there for mitigation?
Everyone has to think along
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Every affected employee is asked to think about the immediate measures. In terms of harm reduction, it is essential to have at least two Strategies to design and evaluate.
This creates contingency plans, which must always be supplemented, edited and updated.
Emergency plans only take effect if the right time to intervene is not missed. This is an important one Objective a functioning error culture.
root cause analysis
To get positive out of a mistake Background for the Future to draw, it is necessary to clarify which circumstances caused the error.
But it is not about the respective person! It is helpful to examine the connections and the background.
Possible causes of errors by employees are
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- lack of specialist knowledge
- lack of skills
- overtaxing
- underload
- emotional exceptional situations
- too little or wrong information
- individual knowledge deficits
- Pressure of time
- pressure to perform
- unclear target agreements
- too complex a process documentation
- organizational flaws
- unclear competence distributions
- leadership deficits
- technical deficiencies
- wrong decisions
- a lack of inner attitude
Several causes interlock
Often, several causes fall together or interlock. It is therefore not always easy to analyze the situation accurately.
The analysis is about persistently asking questions and not being satisfied with “first answers”.
Difference to scapegoat culture
When the employee notices how important the responsible parties take to researching the cause, he learns to contribute with concrete and meaningful answers to uncover the true background.
tick.
Here lies the great contrast to the “scapegoat culture”: This usually only protects what is behind it, defective System in dealing with errors. The real reason is not always immediately apparent. Be persistent in your search for clues! The so-called 5-times-demand-Method:
5 “why” questions
Ask again at the first answer and then again, a total of five times. But it's best not to ask "why", but rather "for what reason" or "why".
Why questions are from the communicative side negative arrested because they emotionally take us back to our childhood and school days:
Checklist for causes research
"Why didn't you do your homework?" "Why isn't your room tidy?" Even then we didn't know the answer, this type of root cause research in the “family error culture” was not very effective.
- When did the error occur?
- When was he discovered?
- What exactly was the error?
- Which circumstances triggered the error?
- Where exactly did the error begin?
- How did it come about?
- What is the impact?
- Is it a single error or is there a chain of
Mistakes? - Has the same error happened to other employees?
- Is there a risk that the employee will be able to make these mistakes again?
- Do errors always follow the same pattern?
- Was revision and / or overload in the game?
- Was it a communication, transmission or presentation error?
- Goods system factors responsible for the error (mit-)?
- Were environmental factors involved?
- What has already been done to mitigate the consequences?
- Can a control center be interposed if necessary?
- What has been done to avoid the error?
- What else can be done about the same bug in the future
to avoid?
Quality and risk management
The link to quality and risk management, which has often been implemented for a long time, is the focus. The legal situation of error culture is also explained. As a result, the current situation is to be studied together.
- The questions to the participants in this phase of the workshop are:
- What is a mistake? How do we define errors?
- Where should the line be drawn between the terms "grossly negligent" and "willful"?
- What are the consequences of messing up mistakes?
- What does constructive error handling mean?
- Where are we now? Where do we want to go?
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