Collection
Design routine work so ordinary human slips do less damage
Separate slips from mistakes, reduce avoidable dependence on memory and vigilance, and use constraints, standardization, workload checks and recovery paths when the cost of an error matters.
12 elements · Explore in any order.
1 checklist · 1 heuristic · 5 principles · 4 protocols · 1 question
12 elements
Decide whether the error was a slip or a mistaken plan
Forgetting a correct step and confidently choosing the wrong step are different failures.
Read the idea PrincipleRedesign a repeat slip before scheduling more training
If capable people keep making the same slip, memory may be the wrong component to improve.
Read the idea ProtocolUse a forcing function for the irreversible step
A warning asks you to be careful. A forcing function changes what is possible.
Read the idea HeuristicMake the safe routine action the default
Defaults spend less vigilance than reminders.
Read the idea PrincipleStandardize the part users should not have to relearn
Variation is expensive when it carries no useful information.
Read the idea PrincipleUse a checklist for omissions, not for pretending judgment disappeared
A checklist is excellent at remembering steps and mediocre at making uncertainty vanish.
Read the idea ProtocolCreate a low-interruption zone for fragile work
Sometimes safety is partly an environmental setting.
Read the idea ChecklistUse an independent check only when it is truly independent
Two signatures can still be one mistake copied twice.
Read the idea ProtocolMeasure workload before blaming attention
Attention is not an unlimited resource you can restore with a motivational email.
Read the idea ProtocolStop the process when the unexpected state invalidates the safety assumptions
A process is not safer because it keeps moving.
Read the idea PrincipleDesign recovery for the error you cannot prevent
Some resilience belongs after the mistake, not only before it.
Read the idea PrincipleDo not discipline away a system defect
Accountability and redesign are different questions; answering one does not remove the other.
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