Understanding the underlying causes of incidents is critical to preventing their recurrence. When incidents, accidents or near misses happen “human error” is often cited as an explanation which covers a wide variety of potential causes, making it difficult to take the proactive steps to address the root causes and create a safer environment.
Incidents caused by human errors can be broadly categorised into 12 factors, the Dirty Dozen. The Dirty Dozen provides a starting point for identifying areas where improvements can be made, whether through process and behavioural change, training initiatives or better resource allocation.
At this point it’s worth noting the difference between human performance and human factors:
- Human Performance: how and why people do what they do
- Human Factors: the science of applying human performance knowledge to the design of machines and processes
This distinction is important because, although the term “Human Factors Dirty Dozen” is widely established terminology, the factors within the dirty dozen are human performance degrading factors. However, the factors listed directly influence human performance within a system, which is the core concern of human factors.
So, while the “Human Performance Dirty Dozen” might offer a more accurate description, the end result is the same, which is to reduce the occurrence of incidents and improve safety.
Where Did The Term “Dirty Dozen” Originate?
The term “Dirty Dozen” was coined by Accident Investigator, Gordon Dupont while working for Transport Canada. Dupont worked alongside various aviation companies, airlines and the Canadian Military as part of an Industry Advisory Committee to investigate human errors in the failure to maintain aeroplanes correctly.
As a result of this analysis Dupont noted 12 key human factors that frequently contributed to incidents within the aviation industry. These 12 factors, the Dirty Dozen, provided insight into the root causes of human error within accidents and serves as the foundation for improving safety.
Since Dupont’s analysis, the Dirty Dozen has been adopted by numerous industries, such as healthcare, to understand and mitigate the human factor.
In a previous blog we discussed the link between patient safety and human factors and how healthcare systems need to be designed to protect ourselves against the known element of human error.
Addressing the individual or environmental aspects of human factors in healthcare, as well as organisational culture and governance, enables the design of medical systems and equipment to be significantly improved.
What Are The Twelve Dirty Dozen Factors?
The Dirty Dozen factors are not ranked in order of importance, however any working environment, from corporate offices to hospitals, can be susceptible to some or all of them. Each human factor is highlighted below, exploring the impact they could have on an organisation and the strategies that could be used to mitigate them.
There isn’t one particular factor which is the number one cause of human error across all industries, however poor communication accounts for 27% of medical malpractice, and is often listed as the main causal factor in aircraft maintenance accident reports, making it one of the most critical human factor elements.
Communication
Poor communication is a frequent cause of incidents, from language barriers, knowledge gaps or even information overload leading to lack of retention. Even minor issues, such as a missed email containing a new safety initiative, can have significant consequences. Prioritising clear and concise communication, confirming understanding and using multiple communication channels can mitigate these communication breakdowns.
Complacency
Complacency can creep into routine tasks when individuals become too comfortable within their roles. For example, a healthcare professional might overlook a small detail in a patient’s care, this lapse in attention, born from performing a certain task multiple times, could lead to a medical error. To combat complacency strategies such as regular training, job rotation and peer cross-checking can be used to combat this human factor.
Knowledge
A healthcare provider may administer the wrong dosage of medication to a patient due to a lack of knowledge or lack of sufficient training. When employees lack the necessary knowledge or skills to undertake their role, errors can happen. Providing comprehensive training as well as fostering a culture of learning and improvement regardless of role will help mitigate this risk.
Distractions
In the workplace various factors can contribute to distractions. These could be environmental factors like noise, personal factors like stress or fatigue and technological distractions like smart watches showing messages and email notifications that can disrupt workflow. Creating a working environment free from distractions is key to eliminating this factor. This could be adding soundproofing to offices, ensuring employees take regular breaks to rest and recharge, or prioritising tasks focusing on one at a time to avoid multitasking.
Teamwork
When team members fail to work collaboratively it can lead to miscommunication, misunderstanding and ultimately incidents. To foster a positive team culture, encourage open and honest two-way communication among team members. This provides opportunities for the team to share feedback and learn from their shared experiences without fear of repercussions.
Fatigue
Fatigue can impair judgement, decision-making and overall performance. For example, during the height of the Covid-19 pandemic healthcare professionals were subjected to prolonged periods of stress, lack of sleep and excessive workload that contributed to fatigue. Being aware and recognising the signs of fatigue in yourself as well as others is key to mitigating this risk.
By setting realistic goals and avoiding over committing by undertaking demanding tasks during periods of peak alertness and avoiding critical tasks during periods of low energy can mitigate the risks associated with fatigue.
Resources
Insufficient resources, such as equipment, personnel or time, can lead to a decrease in standards and increase in accidents. When employees are overworked, understaffed, or lack the necessary tools, they may resort to shortcuts that can compromise both safety and quality. Ensuring that adequate resources are allocated to the right task at the right time as well as implementing strategies to optimise staffing levels which avoids under or overstaffing mitigates the risk associated with lack of resources.
Pressure
Excessive pressure can lead to rushed decisions, poor judgement and ultimately, accidents. For example, when healthcare workers feel pressured to free up beds and rush patient care, they may prioritise speed over safety, leading to errors and mistakes.
In a healthcare environment, the concept of Just Culture involves creating a culture where employees feel comfortable discussing workload concerns and being encouraged to seek additional support when they do feel pressurised. This fosters a positive work culture that reduces stress, promotes well-being and ultimately releases pressure felt by employees.
Assertiveness
A lack of assertiveness can lead to incidents when individuals fail to voice concerns or express their needs. By not speaking up about potential hazards or unsafe working conditions and practices, individuals may inadvertently contribute to accidents.
Additionally, a lack of assertiveness can hinder effective teamwork and communication. Creating and maintaining a positive work culture where employees feel valued and respected as well as empowering employees to take ownership of their work and make decisions can mitigate those risks associated with a lack of assertiveness.
Stress
Stress is a common human experience that can significantly impact both our physical and mental well-being. When individuals are stressed, they may experience difficulties with concentration and decision-making. This can lead to errors and accidents as well as reduced productivity.
To mitigate the negative effects of stress companies can introduce workplace wellness programmes that promote well-being, self-care and a healthy lifestyle. As well as holistic approaches, training programmes for example on effective time management can help relieve stress and improve productivity.
Awareness
A lack of awareness can lead to incidents by diminishing our ability to anticipate potential risks and hazards. When individuals become too focused on their own tasks or fail to consider the broader context, they may overlook important details or make careless mistakes. For example, a construction worker that is engrossed in the task they are undertaking fails to notice a hazard warning before it is too late.
By making employees aware and developing their situational awareness so they are mindful of potential hazards within their immediate environment and wider workplace will help mitigate this human factor and reduce human error in their role.
Norms
Workplace norms, or informal rules and expectations that have built up in the workplace over time, can significantly impact safety. While some norms may be positive and contribute to a strong team culture, others can lead to complacency and a disregard for official safety protocols. Establishing buy-in for all new safety initiatives through consistently enforcing and challenging unsafe behaviours can alter those norms and reduce the negative impact they can have on safety.
How Can Your Organisation Manage The Human Factors Dirty Dozen?
The Dirty Dozen is used to help people think about things that can negatively impact their ability to perform tasks safely and effectively. The list is a starting point for discussing human error in any industry.
Whether a company is looking at improving operational performance and efficiency, or trying to minimise avoidable harm to patients, managing the dirty dozen human factors can have a considerable impact on results. Putting a plan in place which is regularly monitored and measured can create a safer and more positive experience for staff, as well as those using your services.
Verita provides a human performance training course aimed at those responsible for the design and oversight of safety critical tasks, procedures and equipment. This systematic training focuses on improving individual and team safety performance by addressing the Dirty Dozen human factors that can contribute to errors.
As a specialist incident investigator, we analyse data and work with you to pinpoint specific areas where improvements can be made to counteract the Dirty Dozen human factors facing your organisation which contribute to human error.
Our culture management experience also provides a path to assess organisational culture, so that strategic changes can be implemented to create a work environment that empowers employees and drives results.
If you’d like to learn more about the human factors dirty dozen and how we can help your organisation, please book a free consultation or contact Ed Marsden on 020 7494 5670 or [email protected].
