September 18, 2024 | Mark Paradies

Why Do People Stop at Human Error?

Cause of a Quality Issue – Human Error

I saw a letter from the FDA to a drug manufacturer. The FDA stated that the manufacturer had performed an insufficient analysis of a manufacturing quality problem. Why was the analysis insufficient? The analysis stated that “human error” was the root cause of the issue.

This isn’t the first time I’ve seen someone use human error as a root cause. I have written about it before. Perhaps this is my favorite article:

Is Human Error a Root Cause? (Updated)

But why does the FDA say that human error is an insufficient cause? Because “human error” can’t be fixed. To prevent a human error you would have to know more about the cause of the human error. Thus, human error is more of a causal factor than it is a root cause.

Can You Stop Human Errors?

One of the latest fads is the idea that human error can’t be stopped. That human error is inevitable. After all, didn’t Alexander Pope write in An Essay on Criticism:

To err is human, to forgive is divine.

The “experts” say that we need to learn to live with human error. Systems need to be robust enough to survive human error.

This isn’t a bad idea. But I’ve seen corrective actions that stopped particular types of human errors or at least made them very rare.

Going Beyond Human Error

First, if you’ve had a human error cause a manufacturing quality issue, you are at the start of your investigation. You need to understand the causes of the human error.

How can you find the causes of human error? That’s easy!

Use TapRooT® Root Cause Analysis.

TapRooT® Root Cause Analysis was designed to help investigators find fixable causes of human error.

How was TapRooT® Root Cause Analysis built to analyze the root causes of human error? See the full story HERE.

To learn to apply TapRooT® RCA to find the root causes of human performance issues, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. For dates and locations of our public courses, CLICK HERE. To get a quote for a course at your site, call 865-539-2139 or CLICK HERE.

Stopping Human Error

Some want to go beyond the information we have built into the TapRooT® System. They want to be proactive and develop a human performance improvement program. To help people improve the human performance at their company, we wrote a book and developed a course.

The book is titled Stopping Human Error and is available HERE. You can read the forward of the book for free HERE.

When I wrote a book with the title Stopping Human Error, several people told me:

You can’t say that!

They said that it was impossible to stop ALL human errors.

Of course, they were right.

But the title of the book isn’t Stopping ALL Human Errors.

The point of the book and our course (also titled “Stopping Human Error“) is that you can stop some human errors and thereby prevent major accidents, significant losses, patient safety incidents, and other costly failures.

The course is designed to help you understand human error and: