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Sep 1, 2006

On human errors

The first week of classes was very busy, yet it went rather smoothly, for which I am extremely grateful to our dedicated staff and faculty. We messed up just a few things. Specifically, we have misscheduled two classes and then I sent an e-mail to a wrong list of student that got really confused. We also have had a few errors with registering students manually, especially for the off-campus program. At least one graduate fell through the cracks, and her license was delayed significantly. Considering the number of things we got right, it’s not a big deal, really. However, this prompted me to think about the nature of human error and ways of preventing these in the future.

Blaming someone is the last thing on my mind, partly because I messed up some things myself, and partly because I don’t believe it is effective. Where people are, there will be errors; it is just a matter of life. Think of Chernobyl incident, all the NASA disasters, and aviation crashes; most are traceable to human error, despite extraordinary efforts to prevent them. We of course, have nothing comparable in error-prevention, but thankfully, costs of our errors are also incomparably small. No one died, and we did not even cause a lot of complaints. Sometimes it is so great to be not-so-consequential. I still want to look at factors that increase the likelihood of a human error in a social system like ours.

  1. Change in routines. Things like the new registration system just through people off enough to concentrate on the newness, and miss errors. Any change thus should be weighed as a balance between benefits and costs; costs should include increase of error probability.
    New people: a new school director, new coordinator or a new secretary; any new person will make more errors simply because of the learning curve. Now, these learning curves can be steeper for some than for others, and there is no point of blaming people for net learning fast enough. Just like in a classroom – if they are not learning, let’s change teaching. Hurrying them up does not help.
  2. Stress on the system. The more tasks we all do, the more we are likely to screw up on at least some of them. People should do less work, and then they will do it better. I still think elimination of routine, mechanical work will allow us all to think more about what we’re doing, and improve all work processes.
  3. Inefficient procedures. Processes that are too complex, or too time-consuming, will generate errors. For example, if a scheduling process involves four or five information transfers (like we have now), the probability of error is multiplied by the number of times information is passed from one person to another. Streamline and simplify, and the rate of errors will decrease.
  4. Lack of check points. Because we know errors are inevitable, we need to build in some quality assurance processes, and clearly identify who and when does check what.

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