Application Of Human Factors Research Articles

Getting to Zero and Beyond

The Society of Petroleum Engineers (SPE) technical report, Getting to Zero and Beyond: The Path Forward, sets the stage for continuing the discussion across the industry of the essential actions the industry must undertake to attain and sustain zero harm. The report is a compilation of discussions from various SPE sessions and expands on those discussions to identify and evaluate actions that may aid the industry by exploring current thinking and views; incorporating experiences and learnings from other industries that are mature in the application of human factors; and suggesting the next steps that will enable the oil and gas industry to meet an expectation of zero harm. Introduction The goal of health, safety, and environment (HSE) programs and departments is to eliminate incidents that produce harm whether to people, the environment, or property. But somehow the industry has settled into a comfort zone, a zone that tolerates incident occurrence and satisfaction with incremental improvement. Phrases such as “you should have seen the way it was before” or “but we are better than we were” are heard and some-how enable us to accept that what we are doing is sufficient, good, and OK. Industry safety statistics were the subject of an analysis conducted using International Association of Oil & Gas Producers (IOGP) member company annual safety data. The findings showed that in the period from 2014 to 2016, the lost-time injury frequency and total recordable injury frequency both posted an incremental decrease (Fig. 1). However, during the same period, the fatal accident rate showed an increase (Fig. 2). In June, IOGP released its annual Safety Performance Indicators for 2017. Although the 2017 statistics illustrate an improvement in the number of fatalities, the number of fatal incidents increased in 2017 (IOGP 2018). Most striking is the realization that the top three causes of fatal incidents that occur in the global upstream oil and gas industry have remained the same since IOGP first began collecting the data in 2010. Fundamentally, fatalities are occurring despite the industry implementing traditional HSE efforts such as IOGP’s Life-Saving Rules, management systems, training programs, and targeted injury campaigns. What needs to occur is to challenge the current mindset, the ingrained culture. What if we could reject this incremental mindset and make the leap to be satisfied only when we are attaining and sustaining zero harm? That is exactly what a group of SPE members did. They united, starting in 2010, to change industry thinking—to challenge incremental HSE performance improvement, and to create “zero thinking,” not as the end or long game, but as the starting point to defining HSE performance. Their work and efforts have culminated into a recently issued SPE technical report titled Getting to Zero and Beyond: The Path Forward.

Human Factors in Cybersecurity – Perspectives from Industries

Today, cybersecurity is impacting every individual and industry, but the level of effort from the human factors community seems negligible compared to the magnitude of the current security challenge. This panel invites professionals in the healthcare, computer and network, higher education, and automotive industries to share experiences, lessons learned and solutions. The panel characterizes the security landscape in different industries and facilitate discussion on human factors research and applications to address the formidable security challenge.

Forensic Human Factors 101: Interactive Transportation and Product Liability Case Studies

This special joint session with shared interest from multiple technical groups (Forensics Professional Group, Product Design Technical Group, Safety Technical Group, and Surface Transportation Technical Group) provides audience members with an opportunity to conduct a forensic analysis of two cases involving human factors issues. The audience will form four groups in order to conduct their analysis of the behavior and actions of either the plaintiff or the defendant(s) involved in their assigned case. Participants in this session will be provided with information about the case they are analyzing, including descriptions of the circumstances surrounding the case and other factual information required to conduct a forensic analysis. One case will involve a collision between a commercial vehicle and a pedestrian, while the other will relate to the alleged failure of an air regulator utilized in diving. The teams will be asked to develop outlines of expert opinions relying on their knowledge, experience, and familiarity with applicable research. At the conclusion of the teams’ discussions, each team will briefly present the opinions reached by the team. To conclude the session, the audience will have the opportunity to discuss both cases and the value of human factors professionals in litigation. This session will emphasize the broad application of human factors and that forensic human factors work is accessible to a variety of practitioners.

Shift-Work Fatigue in the Petroleum Industry: A Proactive Countermeasure Using Light Cues

This article, written by Special Publications Editor Adam Wilson, contains highlights of paper SPE 187048, “Shift-Work Fatigue in the Petroleum Industry: A Proactive Fatigue Countermeasure,” by Koos Meijer, KM Human Factors Engineering; Martin Robb, SPE, Human Factors Applications; and Jasper Smit, CGE Risk Management Solutions, prepared for the 2017 SPE Annual Technical Conference and Exhibition, San Antonio, Texas, USA, 9–11 October. The paper has not been peer reviewed. Insomnia is a common problem in offshore shift-work environments. In rotating shift-work environments, daylight and darkness cues are incongruent with sleep and work schedules. As a result, many shift workers find it hard to adapt to the schedule, resulting in suboptimal sleeping patterns and increased workforce fatigue. This paper presents a scientific method for reducing fatigue risks in oil and gas organizations that operate a slowly rotating shift schedule. Sleep and Fatigue in Offshore Shift-Work Environments Humans are diurnal (i.e., day animals); because of this, our circadian rhythm is programmed to ensure that alertness, concentration, and other aspects relating to job performance are highest during the day. Our circadian rhythm makes us feel sleepy in the evenings and ensures that we can maintain restorative sleep during the night. The bodily processes related to this are maintained in the suprachiasmatic nucleus (SCN), which is in the anterior hypothalamus in the brain and is synchronized with the day/night cycle. During the abrupt transition to an offshore night working schedule, the sleep and wake timings of our biorhythm become misaligned with those of the work schedule; this is referred to as circadian misalignment, a mismatch between our internal circadian clock and work, sleep, and eating activities. Circadian misalignment also takes place during travel, but, in the case of jet lag, the time-of-day cues at our destination—particularly daylight that contains blue short-wavelength light—enables our biorhythm to realign with the schedule. These time cues include A start-of-the-day cue in the form of bright blue (day) light in the morning A night cue in the form of the absence of this type of light, 3 hours before bedtime During offshore night shifts, these time cues are missing or completely reversed. As a result, some shift workers only partially adjust to the imposed shift-work schedule. These circadian- misaligned shift workers have to work when their body prepares for sleep and have to go to bed when their body tells them to stay active. Performance and Safety. Shift workers’ bodies are preparing for sleep when their schedule demands work, leading to significantly lower performance. This is supported by an increasing number of studies that show that alertness, cognitive capacity, and vigilance of unadapted shift workers are impaired. Job performance suffers as well, leading to a decreased work rate, more quality-control errors, and accidents. An elaborate meta-analytic study has shown that unadapted shift workers have almost a third greater risk of work-related accidents. When shift workers are not able to obtain consistently their required number of hours of sleep after their shifts, a chronic sleep debt begins to accumulate. With each period of insufficient sleep, cognitive performance deteriorates further.

Technical Report Lays Out Path to Zero Harm and Beyond

This article, written by Special Publications Editor Adam Wilson, contains highlights of paper SPE 190485, “Getting to Zero and Beyond,” by J. Jack Hinton, SPE, Baker Hughes, a GE company; Colette M. Glencross, SPE, True North Concepts; Tony Zamora, SPE, ERM; Tom Knode, SPE, Athlon Solutions; and Andrew Dingee, SPE, ADE, prepared for the 2018 SPE International Conference on Health, Safety, Security, Environment, and Social Responsibility, Abu Dhabi, 16–18 April. The paper has not been peer reviewed. Between 2009 and 2016, the Society of Petroleum Engineers facilitated a series of global sessions to develop ideas for the continued improvement of health, safety, and environment (HSE) in the industry. The diverse group of participants generated many valuable ideas for improved performance. The resulting technical report, “Getting to Zero and Beyond: The Path Forward,” sets the stage for continuing the discussion across the industry of the essential steps the industry must take to sustain zero harm. Introduction For more than 2 decades, the oil and gas industry has set HSE goals that are focused on reducing incidents with the ultimate intended outcome that no one is hurt and no releases occur. The concept of zero harm, therefore, is not new to the industry. What has been a challenge for decades, however, is aligning on an effective pathway to achieve these goals. To attain zero harm, a step change in thinking, performance, and alignment around HSE is required across the industry. When faced with these challenges, the industry’s alignment on an expectation of zero harm must encompass managing its risks as a high-reliability industry, and, given this goal, many opportunities exist for companies to focus their efforts on moving toward implementing generative characteristics common to high-reliability organizations. Next Steps Shift From Zero as a Goal to Zero as an Expectation. To eliminate catastrophic events in the oil and gas industry, it must revise the vision of zero. Defining zero harm as a goal implies that incremental safety-performance targets can be set, acknowledging that operations will harm today. Further, this thinking can lead to a detrimental focus on incidents and injuries that may lead to under-reporting of incidents, gaming of statistics, manipulation of incident definitions, and overly aggressive management of injury cases. A goal of zero suggests an unattainable numerical target of perfection. Rather, the industry needs to think of zero harm as an expectation at each and every moment. It must acknowledge the risks in the industry and, at the same time, expect that its people will go home safe today. Perhaps this is a nuanced, subtle shift in thinking—from a goal of zero harm to an expectation of zero harm—but the difference between the two is the difference between focusing on future improvement and focusing on safety in the moment. This shift in mindset is imperative to eliminating catastrophic incidents. Continue To Progress the Application of Human Factors. The cultural shift to being proactive, and ultimately to being generative, is causing a healthy questioning of how the industry has managed HSE.

Erratum

Nair, C., Tsiopanos, K., Martin, R., & Marshall, G. (2018). Increasing warehouse productivity with an ergonomic handheld scanner. Ergonomics in Design: The Quarterly of Human Factors Applications, 26(3), 23–31. (Original DOI: 10.1177/1064804618757281) In the above article, two of the author photos were switched. The correct photos and biographies are given below.

Structured redesign of a hospital-based code response team using Six Sigma tools and human factors principles to facilitate teamwork

Abstract Introduction Response to in-hospital cardiac arrest (a “code”) requires the coordinated efforts of a team of medical professionals in a high-stress, high-risk healthcare setting. This can lead to a chaotic situation. Excessive noise and confusion must be improved to deliver the most effective care. Purpose To develop a paradigm for efficient and effective code response. Methods An interprofessional team used Six Sigma tools to identify characteristics of an “ideal” process for the two identified phases of code response. Further discussion and application of human factors engineering principles produced a paradigm for the code response process. Discussion/conclusions The aim of this structured redesign of our institution's code response process was to reduce the amount of nonproductive noise and confusion during code response through clarification of roles and responsibilities of code team members. The application of engineering principles and interprofessional nature of the redesign group were vital to the successful redesign process.

Erratum

Mououdi, M. A., Akbari, J., & Mohammadi Khoshoei, M. (2018). Measuring the external ear for hearing protection device design. Ergonomics in Design: The Quarterly of Human Factors Applications. Advance online publication. (Original DOI: 10.1177/1064804617731177)

Persistence of Healthcare-Associated (Nosocomial) Infections Due to Inadequate Hand Hygiene: Part 3—Application of Human Factors Engineering to an Ozone Hand Sanitizer

Compliance to hand-hygiene guidelines in healthcare facilities remains disappointingly low for a variety of human-factors (HF) reasons. A device HF-engineered for convenient and effective use even under high-workload conditions could contribute to better compliance, and consequently to reduction in healthcare-acquired infections. We present an overview of the efficacy of a passive hand-spray device that uses solubilized ozone—a strong, safe, non-irritant biocide having broad-spectrum antimicrobial properties—on glass surface, pigskin, and synthetic human skin matrix.

A single-item assessment for remaining mental resources: development and validation of the Gas Tank Questionnaire (GTQ)

ABSTRACTMeasuring workload accurately is critical for human factors research and applications. However, if the instruments we use to measure workload are burdensome for participants to complete, we may find ourselves in the ironic position of increasing workload simply by measuring it. We present a pair of studies that suggest the NASA-TLX, a widely-used workload metric, increases workload for participants who complete it, and consequently may hurt performance and upwardly bias the estimates it produces. We found that repeated administration of the NASA-TLX increased workload by 18%, and more than doubled the performance decrement on a simple vigilance task. Single-item measures may be a simple way to avoid burdening participants unnecessarily while still obtaining valuable insight into participant cognitive state. In line with the attentional resource theory, we validate a measure that asks participants to ‘think about [their] brain as an engine,’ and to indicate inside a rectangle ‘how much gas [they] have left right now.’ The Gas Tank Questionnaire performs well when compared against other subjective measures and when validated against physiological measures. Just as human factors professionals are careful to design systems to minimise unnecessary cognitive load, researchers should take similar care when selecting measures for studies.

Human Factors in Pharmacy

Medication errors in the ambulatory setting are common and contribute to significant morbidity and mortality. Given the Institute of Medicine’s recommendation of adopting a systems-based approach to improving medication safety, research has been conducted utilizing human factors and ergonomics conceptual frameworks, approaches, and methods to study pharmacies and pharmacists. This panel will focus on how human factors principles and models have been adapted for contexts where medications are managed. Individual projects address pediatric patients’ medication-related needs, over-the-counter medication safety for older adults, anticoagulation management, automated prescription tracking, and medication safety-related decision making by healthcare professionals. These studies span settings from community pharmacies to inpatient pharmacies to specialty clinics and patients’ homes. By presenting a sample of the growing body of human factors work in pharmacy, this panel will offer unique implications for human factors theory, methods, and application in this important domain.

Improving central line maintenance to reduce central line-associated bloodstream infections

A human factors engineering-based intervention aimed at the modification of task behavior to increase adherence to best practices and the reduction of central line-associated bloodstream infections (CLABSI). The hypothesis was tested that a central line maintenance kit would improve adherence and reduce CLABSI compared with a standard, nonkit-based method of performing central line maintenance. The study design was a 29-month prospective, interventional, nonrandomized, observational, and clinical research study using a pre-post implementation assessment. The study was conducted at a tertiary hospital in the southwestern United States, with participants recruited from a total of 6 patient units (including intensive care units and general wards). A total of 95 nurses and 151 patients volunteered to participate in the study. A central line maintenance kit was developed that incorporated human factors engineering design principles. This kit was implemented hospitalwide during the clinical study to assess the intervention's influence on protocol adherence and clinical outcomes compared with a preimplementation control condition (no kit use). The results of this clinical observations study suggest that a human factors engineering-based kit improved adherence to best practices during central line maintenance. In addition, the number of CLABSIs was significantly reduced during the postimplementation period. The application of human factors engineering design principles in the development of medical kits can improve protocol adherence and clinical outcomes.

Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care

Health care workers (HCWs) are recommended to wear nonsterile clinical gloves (NSCG) for direct contact with blood and body fluids. However, there is evidence of extensive inappropriate NSCG use. A mixed-methods study comprising observation of NSCG use in 2 acute hospitals and semistructured HCW interviews. Qualitative data were categorized using thematic analysis. Findings were mapped to the Systems Engineering Initiative for Patient Safety model and used to develop a strategy for improving NSCG use. Two hundred seventy-eight procedures performed in 178 episodes of care involved the use of NSCG. NSCG were inappropriate for 59% of procedures (165 out of 278). Risk of cross-contamination occurred in 49% (87 out of 178) episodes. Twenty-six HCWs were interviewed; emotion and socialization were key factors influencing decisions to use NSCG. Data from observation and thematic analysis were mapped to 6 interacting components of the Systems Engineering Initiative for Patient Safety work system. Interventions targeting each component informed quality improvement strategies CONCLUSIONS: Despite intense promotion of hand hygiene as the key measure to protect patients from health care-associated infection, NSCG dominate routine clinical practice and potential cross-contamination occurs in 50% of care episodes. Such practice is associated with significant environmental and financial costs and adversely affects patient safety. The application of human factors and ergonomics to the complex drivers of inappropriate NSCG behavior may be more effective than conventional approaches of education and policy in achieving the goal of preventing health care-associated infection and improving patient safety.

Use of prone position restraint within a mental health trust

PurposeThe purpose of this paper is to improve the quality of care of patients presenting with challenging behaviour.Design/methodology/approachCurrent guidelines are described, and adherence to the standards is audited, with a particular emphasis on physical restraint.FindingsThe results of the clinical audit revealed that in the substantial majority of episodes of challenging behaviour, non-physical techniques were used prior to the need to intervene with physical restraint; however, when physical restraint was used, there was limited use of staff debriefs to facilitate reflection- and work-based learning. A potential diagnostic link to the likelihood of use of prone position restraint was also a finding. The results of a quality improvement project undertaken in response to the findings of the clinical audit demonstrated significant and sustained improvements in adherence to most standards.Practical implicationsContinuous improvements to the safety of both patients and staff when managing acute challenging behaviour requires ongoing quality improvement interventions underpinned by the application of human factors principles.Originality/valueThe completion of this audit cycle suggests that it is useful to measure specific points of care processes, however, continuous improvement interventions are indicated to lead to sustained improvement – in this paper this is demonstrated by the safer management of challenging behaviour.

Evaluation of Recombinant Human FGF-2 and PDGF-BB in Periodontal Regeneration: A Systematic Review and Meta-Analysis

The prognosis for successful treatment of periodontal diseases is generally poor. Current therapeutic strategies often fail to regenerate infected periodontium. Recently an alternative strategy has been developed that combines conventional treatment with the application of recombinant human growth factors (rhGFs). But ambiguities in existed studies on the clinical efficacy of rhGFs do not permit either the identification of the specific growth factors effective for therapeutic interventions or the optimal concentration of them. Neither is it known whether the same rhGF can stimulate regeneration of both soft tissue and bone, or whether different patient populations call for differential use of the growth factors. In order to explore these issues, a meta-analysis was carried out. Particular attention was given to the therapeutic impact of fibroblast growth factor 2(FGF-2) and platelet derived growth factor BB (PDGF-BB). Our findings indicate that 0.3% rhFGF-2 and 0.3 mg/ml rhPDGF-BB show a greater capacity for periodontal regeneration than other concentrations and superiority to control groups with statistical significance. In the case of patients suffering only from gingival recession, however, the application of rhPDGF-BB produces no significant regenerative advantage. The findings of this study can potentially endow clinicians with guidelines for the appropriate application of these two rhGFs.

Application of Human Factors and Ergonomics in Improving Patient Safety Culture

Patient safety is a serious global public health issue. Estimates show that in developed countries as many as one in 10 patients is harmed while receiving hospital care. Increasingly complex healthcare, involvement of multiple disciplines and varied sources of information all contribute to the increasing likelihood and impact of medical errors. Different approaches and methods have been utilized and applied to optimize patient safety issues worldwide. Human factors and ergonomics provides a ‘tried and true’ framework for building and strengthening that elusive safety culture by correcting the mismatch between individuals, the equipments, systems, and process in which they work in, we can improve patient safety.

A Behavioral Interpretation of Situation Awareness: Prospects for Organizational Behavior Management

ABSTRACTSituation awareness (SA) is a construct used in human factors research and application. It is typically employed in the design of equipment to facilitate rapid and adaptive responding in dynamic and high-risk environments. Although the theory backing the SA concept is not entirely compatible with behavioral philosophy, components of the analysis and measures employed in SA work can benefit researchers and practitioners in Organizational Behavior Management (OBM). The present discussion includes (a) the definition and context for SA, (b) a behavioral interpretation of SA, (c) the assessment tools used in SA work, and (d) the relevance of SA to behavioral research. This discussion is pertinent to behavior analysts who work in industries where SA terminology is used and seek analytic tools to guide the design of effective interventions.

Human factors in the design of medical devices – Approaches to meeting international standards in the European Union and USA

This paper focuses on the challenges of meeting agency requirements as it pertains to the application of human factors in the medical device development (MDD) process. Individual case studies of the design and development process for 18 medical device manufacturers located in the US and EU were analyzed and compared using a multiple case study design. The results indicate that there are four main challenges in implementing international standards. These include a lack of direct access to users for the purposes of device development; a lack of understanding by users with regards to the impact of their feedback on the development process; contract formalities limiting user exchanges; and the attitude of clinical users directly impacting on the device developer's invitation to participate in the development processes. The barriers presented in this research have the potential to be resolved but only with greater commitment by both medical device users and developers.

Will the new FDA Human Factors Guidance Help Curb Ethical Dilemmas in Healthcare Usability Testing?

While the FDA provides guidance documents on the application of human factors and usability engineering (HF/UE) to medical devices, the non-specific, recommendatory nature of these documents can lead to varying interpretation by the different entities involved in the HF/UE process. While appropriate HF/UE processes are beneficial to all stakeholders, whether it be the end user, the patient, the medical device manufacturer, a third party HF/UE consultant, or the FDA, the lack of a common understanding of the process combined with the differing perspectives, constraints, and drivers of each party, can lead to inconsistent, and less-than-ideal, implementation of HF/UE. This is exacerbated by the fact that financial incentives may not be aligned with optimizing safety and usability at the expense of development time. This presents the potential for business and ethical conflicts among the involved parties. Our expert panel will review the perspectives of the various stakeholders involved in the HF/UE process and facilitate a meaningful discussion on how a common understanding of HF/UE as it relates to medical device development and regulatory approval can be achieved across the medical device industry. We will focus on the implications of improper application of HF/UE processes and methods to better manage discrepancies in HF/UE implementation, and discuss the impact of the recently-released FDA final guidance.

57: The Application of Human Factors and System Engineering in Determining the Impact of Technology on Radiation Therapy Safety

57: The Application of Human Factors and System Engineering in Determining the Impact of Technology on Radiation Therapy Safety