A Systematic Approach to Human Error Reduction: Investigations, Root Cause Determination and CAPA Effectiveness

    /Ginette  /Collazo, Ph.D.speaker of Training Doyensinvite
    Speaker: Ginette Collazo, Ph.D.

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    Duration: 90 Minutes
    Product Code: 50895
    Level: Intermediate

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If you work in the GMP regulated industry you not only need to address human error deviations because they are an inconvenience, you must do it because the regulation requires it. The CFR - Code of Federal Regulations Title 21 Subpart B_Organization and Personnel Sec. 211.22 talks about the “Responsibilities of quality control unit” and it states that "(a) There shall be a quality control unit that shall have the responsibility and authority to approve or reject all components, drug product containers, closures, in-process materials, packaging material, labeling, and drug products, and the authority to review production records to assure that no errors have occurred or, if errors have occurred, that they have been fully investigated…”

That being said Human Error is NOT a root cause. Human errors start at the design stage. From procedures, training, and workplace environment many variables that affect human behavior CAN be controlled for human error reduction. To work with these challenges, it is essential to understand human behavior, the psychology of error and root causes for human error deviations as well as implementing a process exclusively dedicated to investigating and “fixing” these problems.

This human error prevention training offers practical approaches and models for addressing and controlling human error in GMP related environments by using a particular methodology to correct, prevent and avoid reoccurrence of these matters.


We need to be able to explain human behavior. Did the human fail because process weaknesses set them for failure? Do procedures provide for all information and clearly indicate critical steps and warning or cautions associated with steps? Do systems work for manufacturing or it’s the other way around? These are all tough questions to ask, but most importantly answer.

This training would provide tools that can be implemented and used after this event for human error reduction. These include practical tools. We will discuss human error categories, near root causes and root causes for human error deviations. We will discuss latest trends in human error issues in the industry.


• Human error as the root cause
• What is human error
• Controlling human error
• Root cause determination
• Types of human error
• Human error and training: when and where
• Human error rates and measurement
• Trending and tracking
• Prediction
• CAPA effectiveness


• Understand the psychology of error
• Regulatory requirements in GMP environments for managing human performance deviations
• Root cause determination and investigations
• Root cause determination tool
• Establishing the human error rate at your site
• Implementing the human error reduction program
• Metrics and KPI’s


• Training managers and coordinators
• Operations
• Manufacturing
• Plant engineering
• QA/QC staff
• Process excellence/improvement professionals
• Industrial/process engineers
• Compliance officers
• Regulatory/legislative affairs professionals
• General/corporate counsel


Years of Experience: 23+ years

Areas of Expertise: Engineering Psychology and Human Reliability

Ginette Collazo, Ph. D. is an Industrial-Organizational Psychologist with 20 years of experience that specializes in Engineering Psychology and Human Reliability, disciplines that study the interaction between human behavior and productivity. She has held positions leading training and human reliability programs in the Pharmaceutical and Medical Device Manufacturing Industry.

Ten years ago, Dr. Collazo established Human Error Solutions (HES), a Florida based boutique consulting firm, where she has been able to position herself as one of the few Human Error Reduction Experts in the world. HES, led by Dr. Collazo, developed a unique methodology for human error investigations, cause determination, CA-PA development and effectiveness that has been implemented and proven amongst different industries globally. This scientific method has been applied in critical quality situations and workplace accidents.

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