Continuous improvement for a procedure management system to reduce the incidence of human procedure execution failures

A system for continuously improving procedure management system components of a procedure management system to generate revised human operating procedures that mitigates human procedure execution failures, comprising:

• at least one workstation which interacts with at least one user;
• a database having recorded actual incidents stored in a non-transitory media collectively recording a plurality human procedural execution failures;
• a software tool that is coupled to interact with said workstation and said datasbase, said software tool including a physical machine-readable storage medium having stored thereon computer code, said computer code comprising:
• code for defining at least one of a plurality of specific and actionable failure modes (root cause) for each of said plurality of human procedural execution failures;
• code for mapping said plurality of root causes to at least one of a plurality of stages of human operator execution for said human operating procedures where said plurality of root causes manifest, and to at least one of a plurality of human intervention activities that said human operator failed to correctly execute (procedure deficiency);
• code for mapping each of said plurality of root causes to at least one of said plurality of procedure management components that may have generated said procedure deficiency;
• code for analyzing said recorded actual incidents of said plurality of human procedural execution failures to identify at least one assignable root cause from said plurality of root causes;
• code for updating at least one of said plurality of procedure management components to mitigate said assignable root cause, and
• code for after said updating, using said procedure management system to change at least one of said human operating procedures or to generate a new human operating procedure, wherein said change to said human operating procedures or addition of said new human operating procedure reduces an incidence of said human procedural execution failures.

A non-transitory computer-readable medium having stored instructions for continuously improving a procedure management system comprising a plurality of procedure management components that generates human operating procedures for a human operator to execute, said stored instructions comprising:

• code for defining at least one of a plurality of specific and actionable failure modes (root causes) for each of a plurality of human procedural execution failures;
• code for mapping said plurality of root causes to at least one of a plurality of stages of human operator execution for said human operating procedures where said plurality of root causes manifest, and to at least one of a plurality of human intervention activities that said human operator failed to correctly execute (procedure deficiency);
• code for mapping each of said plurality of root causes to at least one of said plurality of procedure management components that may have generated said procedure deficiency;
• code for analyzing recorded actual incidents of said plurality of human procedural execution failures to identify at least one assignable root cause from said plurality of root causes, and
• code for updating at least one of plurality of procedure management components to mitigate said assignable root cause,
• wherein after said updating, said procedure management system is operable to change at least one of said human operating procedures or to generate a new human operating procedure, wherein said change to said human operating procedures or addition of said new human operating procedure reduces an incidence of said human procedural execution failures.