{
  "schema": "vedokrok.public-item.v1",
  "release_id": "MHC-RPUB-20260920-75ad787a",
  "url": "/knowledge/redesign-a-repeat-slip-before-scheduling-more-training",
  "id": "MHC-D-RESEARCH-0482",
  "version": "0.1.0",
  "title": "Redesign a repeat slip before scheduling more training",
  "summary": "If capable people keep making the same slip, memory may be the wrong component to improve.",
  "kind": "principle",
  "body": "Move the safeguard into the process: checklist, required field, automatic validation, clearer interface, distinct controls or another system change. Use education for what people genuinely need to know, but stop expecting memory and vigilance to compensate forever for a repeatable design trap.",
  "limits": [
    "Over-automation can create brittle workflows and hidden workarounds; test the redesign with real users."
  ],
  "topics": [
    "union-human-factors-error-resistant-work"
  ],
  "intents": [],
  "source_ids": [
    "RS-0DC97A17124805E6",
    "RS-071174D15DDE671E"
  ],
  "evidence": [
    {
      "claim": "AHRQ recommends redesign strategies such as checklists, forcing functions, reduced unnecessary variation and distraction control for slip-prone routine work.",
      "source_id": "RS-0DC97A17124805E6",
      "role": "supports",
      "note": "The right control depends on the task and can create new failure modes if poorly designed.",
      "locator": "Slips and system redesign"
    },
    {
      "claim": "AHRQ just-culture guidance separates inadvertent human error from at-risk or reckless behavioral choices and recommends system design rather than blame as the default response to ordinary error.",
      "source_id": "RS-071174D15DDE671E",
      "role": "supports",
      "note": "Serious misconduct, policy violations and legal obligations require their own accountability process.",
      "locator": "System design, behavioral choices and accountability"
    }
  ],
  "use_when": [
    "The same routine omission recurs among competent people despite reminders and retraining."
  ],
  "avoid_when": [
    "Over-automation can create brittle workflows and hidden workarounds; test the redesign with real users."
  ],
  "example": "If users repeatedly forget to select a mandatory sales area, validate it before activation instead of sending the same reminder email.",
  "check": "The next occurrence is harder or more visible because the workflow changed, not merely because somebody was warned.",
  "sources": [
    {
      "id": "RS-0DC97A17124805E6",
      "title": "Systems Approach",
      "url": "https://psnet.ahrq.gov/primer/systems-approach"
    },
    {
      "id": "RS-071174D15DDE671E",
      "title": "Staff Empowerment: System design, behavioral choices, learning systems and accountability",
      "url": "https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module3/mod3-facguide.html"
    }
  ],
  "relations": [
    {
      "from": "MHC-D-RESEARCH-0482",
      "to": "MHC-D-RESEARCH-0483",
      "type": "useful_with",
      "url": "/knowledge/use-a-forcing-function-for-the-irreversible-step"
    }
  ],
  "collections": [
    {
      "id": "RC-76433B7AE15B054C",
      "title": "Design routine work so ordinary human slips do less damage",
      "url": "/collections/design-routine-work-so-ordinary-human-slips-do-less-damage"
    }
  ]
}