Menu
ExpertiseDeviation managementDecide, investigate, manageQuality system managementDeviations, CAPA, change controlReducing human errorReal root causes, V.A.K. checkBatch recordsSimplify and speed up reviewBatch release flowManage the flow, remove bottlenecksQuality cultureFrom leadership to the shop floorChange controlDescribe, assess, manageQuality organisationOne process, one teamDocumentation and trainingWith our partner SinfonyEffective Quality BrigadeReinforcements trained in our methodsAll our expertise →
Case studiesResourcesShopAboutContact
FR

Case study · Human error

SENTINELLE programme: 47% fewer “human error” deviations in 6 months

Repeated retraining with no lasting effect: this site changed its approach. A human error expert per area, trained to become autonomous, and short shop-floor rituals to handle weak signals before they turn into errors.

Clinical R&D site of about 1,000 people · packaging and distribution2023Completed

The results

−47 %“human error” deviations per month9 → 5
−27 %total deviations per month34 → 25
157weak signals reported in 3 months
−76 %“human error” deviations in packaging6 → 1 per month

Monthly averages for 2022 compared with 2023. Coaching from May to October 2023.

The starting point

  • A packaging unit of about 200 people, in 2 shifts, with very manual operations.
  • 2022: 408 deviations, 108 of them due to human error, i.e. 26%.
  • Repeated retraining with no lasting effect.

What we did together

  1. AssessA flash assessment of the site, then an introduction for the teams.
  2. Appoint expertsA “human error expert” per area (packaging, warehouse, PSL / PPL), coached to become autonomous.
  3. Adapt the toolsA tool to help analyse human errors, adapted to the site.
  4. Put in place 4 ritualsWeak signal reporting, task observations, “15 minutes for Quality” and a short-term action plan.
  5. May → Oct. 2023Coach for 6 monthsShop-floor coaching, until the experts are autonomous.

Errors fall in the coached areas

“Human error” deviations opened per month, on average, in 2022 and then in 2023.

20222023

Weak signals handled before they become errors

Two data loggers side by side

set to different ranges: placed at either end, with colour coding.

A heavy box stored up high

awaiting inspection: the waiting area was redesigned with the shop floor.

Self-validation

of labels and leaflets: criteria defined and a double check.

Invoices entered by hand

held up at customs: invoicing software, so the patient receives their treatment.

Our takeaways

Task observations created strong moments of awareness, and “15 minutes for Quality” was well adopted. The experts improved from 71% to 79–100% on their observation grid, against a target of 75%.

The approaches used

Reducing human error

Our advice if you’re getting started

  • Keep the rituals alive between the coach’s visits: that’s where everything happens.
  • Rely on internal experts, as close as possible to the shop floor, rather than on retraining.

Do human errors keep coming back despite training?

Let’s talk about your situation: we’ll show you how to handle weak signals before they become deviations.

Discover SENTINELLEContact us