Mindfulness Training: A Means to Reduce Human Error

Human error is a broad category that includes the common clearly identifiable, easily diagnosable and seemingly excusable mistakes we all make. Error encompasses all those occasions when a planned sequence of mental or physical activities fails to achieve its intended outcome, and these failures cannot be attributed to the intervention of some chance agency. The definition of human error may be complex but the outcome in the workplace, where accuracy is paramount, is not.¹ Human error is the major cause of drug and device manufacturing failures and recalls.

Error reduction was addressed more than 30 years ago by W. Edwards Deming, the American statistician. He cited the need for a fresh approach to reduce mistakes and defective workmanship.² Deming noted that in many organizations human error accounts for more than half of unnecessary business expenses. Of that portion, Deming's rule of thumb is that about 85% result from automatic errors of execution, whose causes remain inadequately understood and addressed.³

Minimizing or preventing mistakes is the linchpin of quality. It defines quality control in its strictest sense and is the key to maintaining an effective quality program. Although quality training is regarded as an essential activity and required by food and drug law and Good Manufacturing Practice regulations, the practice of mindfulness is relatively new and it is highly unlikely to have been employed or even considered by management. In my opinion, most individuals have little knowledge of its potential value.

This article discusses the causes of human mistakes, mistake proofing and mindfulness training as a means to improve reading ability, working memory and task focus. I have added a 10-15 minute mindfulness exercise designed to increase your ability to pay attention.

Causes of Human Error

The causes of human mistakes are complex. Researchers have determined that causes vary according to the level of cognitive control used at the time. "Cognitive control" is the level of conscious mental processing a person must apply to perform an activity. There are three levels of cognitive control: skill-based, rule-based and knowledge-based.⁴ Mistakes at the skill-based level are normally due to inattention such as "mind wandering," defined as a shift in attention from a task to unrelated concerns. Most people's minds wander more often than they might think. In one study, students reported that their minds wandered 5.4 times in a 45-minute session. Depending upon the experiment, people tend to spend up to half their time not thinking about the task at hand, even when they have been told explicitly to pay attention.^5 

Multi-tasking is another common cause of skill-based errors. Multi-tasking impairs the ability to think. Individuals do their best thinking by slowing down and concentrating on one task at a time.

Rule-based mistakes normally involve using a good rule in the wrong situation or simply using a bad rule. Choosing the wrong rule is normally the result of either insufficient or extraneous information. A good example is trying to use the same method for electropolishing different metals without understanding the effect on their surface properties.

Mistakes at the knowledge-based level of control usually arise because the human mind has limited processing capacity or inconsistently weighs perceptions, bases decisions on prior convictions and makes spurious correlations in the analysis process.⁶ Whatever the causes, it behooves management to understand them and to provide training to minimize them. Further, experienced employees must be treated differently from trainees because they make different mistakes for different reasons.

Mistake Proofing

Quality personnel that focus on defect prevention or mistake proofing can use principles embodied in the Japanese concept of poka yoke. This system involves the use of any automatic device or method that either makes it impossible for an error to occur or makes the error immediately obvious once it occurs. Unfortunately, poka yoke has not been implemented by medical device or drug companies as often as it should be.⁷  For this reason, it is contingent upon management to seek alternative training methods.

Training

Because cognitive control is a key item responsible for human mistakes, companies should consider reasonable and effective methods known to enhance an employee's cognitive control. One such means is mindfulness training.

"Mindfulness" can be thought of as the art of paying attention with an open and curious mind to present-moment experiences or as the ability to attend to a task without distraction. It also has been defined as a state of non-distraction characterized by full engagement with a current task or situation.⁸ Whatever the definition, mindfulness training can be used to decrease mind wandering and to improve cognitive performance. For the best part of our waking hours, however, most of us are anything but mindful.

Mindfulness training develops attention, discernment, clear seeing and thus wisdom. In this instance, wisdom means knowing the actuality of things rather than being caught in our misperceptions and misapprehensions of reality. And those misperceptions and misapprehensions tend to be truly legion for all of us, no matter who we are, because it is so easy to be caught up in our belief systems, ideas, opinions and prejudices.⁹

In a recent randomized two-week program designed to examine whether mindfulness training would decrease mind wandering and improve cognitive performance, the investigators reported positive results. Mindfulness training improved reading comprehension scores and working memory capacity while simultaneously reducing the occurrence of distracting thoughts. The class emphasized physical and mental strategies that help people maintain focus on the present moment in the face of interrupting thoughts and perceptions. Classes met for 45 minutes four times a week for two weeks. Each class included 10-20 minutes of mindfulness exercises requiring focused attention on some aspect of sensory experience (sensations of breathing or sounds of an audio recording). The course was taught by professionals with extensive teaching experience. Class content provided a clear set of strategies for and a conceptual understanding of how to practice mindfulness. The trainers suggested that cultivating mindfulness is an effective and efficient technique to improve cognitive function.¹⁰

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Final thoughts

According to Douglas Rushkoff, a well-respected recent author and media theorist, a growing and obsessive devotion to information flowing in real time on the Internet and other media interferes with our ability to think clearly.¹¹ Certainly, many educators would agree. Now is the opportune time for management to provide training to improve the working memory capacity, reading ability and task focus of all current employees, particularly those involved in production and quality. Even a brief mindfulness training course can help people rein in their wandering minds and, in doing so, improve fundamental cognitive abilities.

References

1. Sherman M. Human error and quality control in medical devices. MD+DI. 2011;33(5):38-41.
2. Deming WE. Out of the Crisis. Cambridge, MA: MIT Press; 1986.
3. Evans JM. Look for trouble. Quality Progress. December 2006:56-62.
4. Chase RB, Douglas MS. Mistake Proofing-Designing Errors Out. 2002; Productivity Press.
5. Zimmer C. The brain. Discover Magazine. July/August 2009:24-5.
6. Op cit 4.
7. Op cit 1.
8. Siegel D. The Mindful Brain. New York, NY: Norton; 2007.
9. Kabat-Zinn J. Mindfulness for Beginners. Sounds True Inc, 2012.
10. Mrazek MD et al. Mindfulness training improves working memory capacity and GRE performance while reducing mind wandering. Psychological Science. published online March 28, 2013:1-6. Sage Journals website. http://pss.sagepub.com/content/early/2013/03/27/0956797612459659.abstract. Accessed 26 April 2013.
11. Rushkoff D. Present Shock: When Everything Happens Now. New York, NY: Random House Publishing; 2013.
12. Jha AP: Being in the now. Scientific American Mind. March/April 2013:26-33.