When workplace incidents occur, the first instinct is often to blame human error. But is it really the root cause? The Generic Error Modeling System (GEMS Model) provides a revolutionary perspective, emphasizing that human errors are symptoms of deeper systemic issues.
What is the GEMS Model?
Developed by James Reason, the GEMS Model categorizes human errors into predictable patterns, helping us understand how these errors occur within complex systems. Instead of blaming individuals, GEMS shifts the focus to systemic weaknesses that create conditions for errors to happen.
Types of Errors in GEMS
- Slips and Lapses
- Slips: Errors in execution, like pressing the wrong button.
- Lapses: Memory failures, such as forgetting a critical step.
These errors often happen under pressure or fatigue.
- Mistakes
- Rule-Based Mistakes: Applying the wrong rule to a situation.
- Knowledge-Based Mistakes: Decisions made without sufficient information or expertise.
These mistakes stem from a lack of training, unclear instructions, or inadequate systems.
- Violations
- Deliberate deviations from rules or procedures, often due to unclear guidelines or workplace culture.
Why Human Error is NOT the Root Cause
- System Failures Create Errors
Human error doesn’t happen in isolation. It’s influenced by:- Poorly designed systems
- Ineffective training
- Unrealistic workloads
- Blame Culture Limits Improvement
Blaming individuals discourages transparency and hinders organizations from learning from incidents. - Errors Are Predictable and Preventable
GEMS highlights that human errors follow patterns that can be anticipated and mitigated through better system design.
The GEMS Approach to Preventing Incidents
- Design Systems to Minimize Errors:
Simplify processes, provide clear instructions, and design error-proof tools. - Focus on the Latent Conditions:
Identify and address hidden flaws in the system that set the stage for errors. - Promote a Learning Culture:
Encourage reporting of near-misses and incidents without fear of punishment.
Key Takeaway
Accidents are rarely caused by individuals alone. Human errors are the end result of systemic issues that must be addressed to create a safer, more resilient workplace.