Human Error Incidents Research Articles

Determining the significant contributing factors to the occurrence of human errors in the urban construction projects: A Delphi-SWARA study approach

The construction industry is believed to be more susceptible to human errors than other industries because of its unique characteristics, particularly when it comes to urban construction projects (UCP). Despite the considerable attention given to human errors in construction sector, there has been a lack of emphasis on analysing these errors in specific projects like construction in urban environments with distinct complexities. Hence, this paper seeks to determine and assess the critical factors influencing human errors associated with the UCP. In this vein, Three rounds of Delphi surveys were done with 17 specialists in safety and construction management. According to the Delphi survey results, 35 substantial factors that contribute to the incidence of human errors in the UCP were discovered. Then, an empirical questionnaire based on the 5-point Likert scale of measurement was developed and distributed among 37 construction experts to assess the level of impact that each factor on occurring human error in the UCP. The questionnaire had 35 influential factors related to human errors, categorised into five primary divisions (environmental, technological/information systems, individual (permanently related), individual (temporarily related), and organisational). Before the distribution, the reliability and validity of the questionnaire were evaluated and confirmed. The factors were ranked using the Step-wise Weight Assessment Ratio Analysis (SWARA) technique at this point. The research findings indicated that the criterion of “technological factors/information systems” is the most crucial, with the criterion of “individual factors (permanently related)” coming in second and the criterion of “environmental factors” coming in third. The sub-criterion “weak maintenance management systems” scores first in the general ranking of sub-criteria, indicating traditional network systems, the absence of appropriate tools and equipment, and a lack of understanding of required resources. The sub-criterion “defects in details and information and lack of design dynamism” is placed second, while the sub-criterion “violation of safety regulations (use of drugs, etc.)” is ranked third. The study results can help industry practitioners make more educated judgements to minimise and manage human errors in the UCP.

Critical evaluation of applications of artificial intelligence based linguistic models in Occupational Health.

This article explores the impact and potential applications of large language models in Occupational Medicine. Large language models have the ability to provide support for medical decision-making, patient screening, summarization and creation of technical, scientific, and legal documents, training and education for doctors and occupational health teams, as well as patient education, potentially leading to lower costs, reduced time expenditure, and a lower incidence of human errors. Despite promising results and a wide range of applications, large language models also have significant limitations in terms of their accuracy, the risk of generating false information, and incorrect recommendations. Various ethical aspects that have not been well elucidated by the medical and academic communities should also be considered, and the lack of regulation by government entities can create areas of legal uncertainty regarding their use in Occupational Medicine and in the legal environment. Significant future improvements can be expected in these models in the coming years, and further studies on the applications of large language models in Occupational Medicine should be encouraged.

An Empirical Study of the Human Error-Related Factors Leading to Site Accidents in the Iranian Urban Construction Industry

Human errors are one of the major causes of accidents in the construction industry. Human errors can be caused by various factors across diverse types of projects. Hence, this research study seeks to determine the major factors influencing human errors associated with the urban construction industry (UCI). To achieve this, three rounds of Delphi survey were conducted with 17 experts engaged in construction site safety management. The Delphi panel members were determined using a targeted snowball sampling method. According to the results of the Delphi survey, 35 significant factors leading to the incidence of human errors in the UCI were identified and collated. Then, an empirical questionnaire was developed based on a five-point Likert measurement scale and distributed among construction experts to evaluate the impact level of each identified human error in the UCI. The questionnaire included 35 effective factors pertaining to human errors classified into five main groups of environmental factors, information systems/technological factors, individual factors (permanently related), individual factors (temporarily related), and organizational factors. Findings indicate that all evaluated factors are at a higher-than-average level and can be considered as the significant factors leading to the occurrence of site accidents attributed to human errors in the UCI. In addition, the top five most significant factors include improper work and safety culture, low level of technology deployed for equipment and safety protection, violation of safety regulations, rushing to do work, and lack of a proper education system in the organization. The results of this study can be useful for producing better-informed decisions by various major industrial practitioners and site safety managers.

Development of Inspired Therapeutics Pediatric VAD: Benchtop Evaluation of Impeller Performance and Torques for MagLev Motor Design.

Despite the availability of first-generation extracorporeal mechanical circulatory support (MCS) systems that are widely used throughout the world, there is a need for the next generation of smaller, more portable devices (designed without cables and a minimal number of connectors) that can be used in all in-hospital and transport settings to support patients in heart failure. Moreover, a system that can be universally used for all indications for use including cardiopulmonary bypass (CPB), uni- or biventricular support (VAD), extracorporeal membrane oxygenation (ECMO) and respiratory assist that is suitable for use for adult, neonate, and pediatric patients is desirable. Providing a single, well designed, universal technology could reduce the incidence of human errors by limiting the need for training of hospital staff on a single system for a variety of indications throughout the hospital rather than having to train on multiple complex systems. The objective of this manuscript is to describe preliminary research to develop the first prototype pump for use as a ventricular assist device for pediatric patients with the Inspired Universal MCS technology. The Inspired VAD Universal System is an innovative extracorporeal blood pumping system utilizing novel MagLev technology in a single portable integrated motor/controller unit which can power a variety of different disposable pump modules intended for neonate, pediatric, and adult ventricular and respiratory assistance. A prototype of the Inspired Pediatric VAD was constructed to determine the hemodynamic requirements for pediatric applications. The magnitude/range of hydraulic torque of the internal impeller was quantified. The hydrodynamic performance of the prototype pump was benchmarked using a static mock flow loop model containing a heated blood analogue solution to test the pump over a range of rotational speeds (500-6000 RPM), flow rates (0-3.5L/min), and pressures (0 to ~420 mmHg). The device was initially powered by a shaft-driven DC motor in lieu of a full MagLev design, which was also used to calculate the fluid torque acting on the impeller. The pediatric VAD produced flows as high as 4.27L/min against a pressure of 127 mmHg at 6000 RPM and the generated pressure and flow values fell within the desired design specifications. The empirically determined performance and torque values establish the requirements for the magnetically levitated motor design to be used in the Inspired Universal MagLev System. This next step in our research and development is to fabricate a fully integrated and functional magnetically levitated pump, motor and controller system that meets the product requirement specifications and achieves a state of readiness for acute ovine animal studies to verify safety and performance of the system.

Evaluation of preconditions affecting symptomatic human error in general aviation and air carrier aviation accidents

Human error remains the leading cause of accidents in the aviation industry, as technological reliability and system safety have undergone significant improvements. Improved methods are required to model the events resulting in human error incidents. In this study, aviation accident data are evaluated to model the association between the latent and symptomatic causal factors resulting in aviation mishaps. We comparatively analyze National Transportation Safety Board accident data for general aviation and air carrier pilots in order to evaluate potential causal factors. The demonstrated methodology leverages previous work in causal relationships by using multiple-variable logistic regression to model the relationships among latent causal factors, symptomatic causal factors, and accident severity. The Human Factors Analysis and Classification System is applied to define a framework intended to identify focal areas for the safety community to mitigate similar future system failures. The results demonstrate an effective methodology for evaluating the quantitative relationships between symptomatic and latent causal factors, which are not readily apparent based solely on occurrence rates. Furthermore, the results also clarify the differences in causal factors between the selected general aviation and air carrier pilot operations. The usefulness of the framework, transferability to other domains, and possibilities for future research are discussed.

The Human Element in Shipping Casualties as a Process of Risk Homeostasis of the Shipping Business

Evidence for the existence of risk compensation behaviour in the operation of vessels is shown in the paper The Risk Homeostasis Theory (Baniela and Ríos, 2010). In that analysis, it is concluded that the people engaged in the commercial affairs of ships tend to exchange the level of safety standard of vessels for a more profitable and riskier activity, which makes the rate of shipping accidents fluctuate within certain limits. Since the different levels of power and motivation of those involved in the risk-taking process were not considered in that research, it is the aim of this paper to analyse, on the one hand, how the pressure of the shipping market influences the risk behaviour of shipping business decision-makers and to show, on the other hand, how this influence makes them alter their target level of risk and introduce risks related to low operating cost strategies on vessels. This behavioural adaptation to the shipping market demand has led the human element to be regarded as a factor of risk in the activity of commercial vessels. In this context, the increasing incidence of human errors has arisen as a consequence of practices and manning policies established by the managers of shipping companies.

A Revisit to the Recent Human Error Events in Nuclear Power Plants Focused to the Organizational and Safety Culture

Objective: This paper presents additional considerations related to organization and safety culture extracted from recent human error incidents in Korea, such as station blackout(i.e., SBO) in Kori#1. Background: Safety culture has been already highlighted as a major cause of human errors after 1986 Chernobyl accident. After Fukushima accident in Japan, the public acceptance for nuclear energy has taken its toll. Organizational characteristics and culture became elucidated as a major contributor again. Therefore many nuclear countries are re-evaluating their safety culture, and discussing any preparedness and its improvement. On top of that, there was an SBO in 2012 in the Kori#1. Korean public feels frustrated due to the similar human errors causing to a catastrophe like Fukushima accident. Method: This paper reassesses Japan's incidents, and revisits Korea's recent incidents. It focuses on the analysis of the hazards rather than the causes of human errors, the derivation of countermeasures, and their implementation. The preceding incidents and conclusions from Japanese experience are also re-analyzed. The Fukushima accident was an SBO due to the natural disaster such as earthquakes and a successive tsunami. Unlike the Fukushima accident, the Kori#1 incident itself was simple and restored without any loss and radioactive release. However, the fact that the incident was deliberately concealed led to massive distrust. Moreover, the continued violation of rules and organized concealment of the accident are serious signs of a new distorted type of human errors, blatantly revealing the cultural and fundamental weakness of the current organization. Result: We should learn from Japanese experiences who had taken pride in its safety technology and fairly high confidence in safety culture. Japan's first criticality accident in JCO facility splashed cold water on that confidence. It has turned out to be a typical case revealing the problems in the organization and safety culture. Since Japan has failed to gain lessons and countermeasure, the issue persists to the Fukushima incident. Conclusion: Safety culture is not a specific independent element, which makes it difficult to either evaluate it properly or establish countermeasures from the lessons. It may continue to expose similar human errors such as concealment of incident and manipulation of bad data. Application: Not only will this work establish the course of research for organization and safety culture, but this work will also contribute to the revitalization of Korea's nuclear industry from the disappointment after the export contract to UAE.

The public understanding of error in educational assessment

Evidence from recent research suggests that in the UK the public perception of errors in national examinations is that they are simply mistakes; events that are preventable. This perception predominates over the more sophisticated technical view that errors arise from many sources and create an inevitable variability in assessment outcomes. The public perception also seems to invest assessment grades and marks with the precision and accuracy of scientific measurements; a perception that does not sit easily with the academic and professional understanding that grades and marks are assigned rather than measured. However, growing numbers of successful challenges by students to their examination results present an interesting challenge for examination bodies. Such evidence could point to a number of possible causes. For example, there might be an increasing awareness among students of the uncertainty surrounding the grades assigned to their work; or their confidence in the capacity of such assessments to reflect the true quality of their performance may be decreasing. As the numbers of challenges increase year on year, there is growing consensus among assessment experts that public confidence needs to be strengthened. Clearly this may be achieved in a number of ways, e.g. by reducing the incidence of human errors and system breakdowns or by improving the public understanding of the assessment process. The latter tactic prompts calls for greater openness and transparency in all aspects of assessment design and process. However, such calls rarely touch on one of the most enduring dimensions of the problem: the public’s perception of precision and accuracy in educational assessments. This paper argues that this problem partly arises from a misuse of the term ‘measurement’ in educational assessment and that in addition to openness and transparency, any public understanding strategy should seek to reduce the misconceptions it causes.

Human reliability analysis (HRA) techniques and observational clinical HRA

This review explains the nature of human reliability analysis (HRA) methods developed and used for predicting safety in high-risk human activities. HRA techniques have evolved over the years and have become less subjective as a result of inclusion of (i) cognitive factors in the man-machine interface and (ii) high and low dependency levels between human failure events (HFEs). All however remain probabilistic in the assessment of safety. In the translation of these techniques, developed for assessment of safety of high-risk industries (nuclear, aerospace etc.) where catastrophic failures from the man-machine complex interface are fortunately rare, to the clinical operative surgery (with its high incidence of human errors), the system loses subjectivity since the documentation of HFEs can be assessed and studied prospectively on the basis of an objective data capture of errors enacted during a defined clinical activity. The observational clinical-HRA (OC-HRA) was developed specifically for this purpose, initially for laparoscopic general surgery. It has however been used by other surgical specialties. OC-HRA has the additional merit of objective determination of the proficiency of a surgeon in executing specific interventions and is adaptable to the evaluation of safety and proficiency in clinical activities within the preoperative and postoperative periods.

Six steps from head to hand: A simulator based transfer oriented psychological training to improve patient safety

The incidence of human errors in the field of medicine is high. Two strategies to increase patient safety are simulator training and crew resource management (CRM) seminars, psychological courses on human performance and error management. To establish a CRM course combining psychological training on human error with simulator training. Evaluation of a new 1-day training approach targeting physicians, nurses, and paramedics. The course was divided into four modules focusing on situation awareness, task management, teamwork, and decision-making. Each of the modules was set up according to a new six-step approach. The course started with an introduction into good CRM behaviour and an instructor demonstration of a simulator scenario. The participants had to debrief the instructors regarding their human performance. Step 2 was a lecture about the psychological background, and the third step consisted of psychological exercises related to the topic of the module. A psychological exercise in a medical context (MiniSim) made up step 4, which involved a patient simulator. The last two steps were a simulator scenario and a debriefing, as in other simulator courses. A psychologist and a physician were the facilitators in all steps. Two pilot courses were evaluated. Seventeen evaluation questionnaires were received. All participants rated the course as good (10) and very good (7). The psychological exercises were highly valued (good, 5; very good, 11 participants). Thirteen participants agreed that the course content was related to their work. We established the first course curriculum combining psychological teaching with simulator training for healthcare professionals in emergency medicine. Similar concepts using the six-step approach can be applied to other medical specialties.

Lessons from Human Error Incidents in Process Plants

This paper describes four human error incidents in chemical process plants which I have personally observed, and discusses specific lessons from each of them. As often stated by Trevor Kletz, people respond to stories and examples, and hopefully these incidents will be useful in preventing similar incidents in the future. Fortunately none of the incidents resulted in serious safety consequences, although all cost some money and productivity. And, under other circumstances, similar errors in a more hazardous operation could have had serious safety consequences.

A New Metaphor to Display Critical Pulmonary Events during Anesthesia

The anesthesiologist is faced with a fire-hose of information in the operating room. Data from the patient monitors include numerical data, waveforms, control settings, and alarm conditions. During an unexpected event, the anesthesiologist must quickly assess available information in order to diagnose and treat the patient before the patient is injured. However, human error is associated with more than 80% of critical anesthesia incidents and more than 50% of anesthetic deaths.1 In a recent study at the University of Washington, Department of Anesthesiology, 32% of the reported human error incidents were related …

Multivariate Analysis of Human Error Incidents Occurring at Nuclear Power Plants: Several Occurrence Patterns of Observed Human Errors

This paper describes the results obtained in respect of typical human errors together with their information-processing phases, causal factors and situational factors found commonly among incidents analysed at domestic nuclear power plants (NPPs). The Central Research Institute of Electric Power Industry has been conducting detailed and structured analysis of all incidents reported during the last 31 years and has stored them in a database. At first, all case studies were classified into several categories. Next, multivariate analysis was applied. These results suggested that there were several occurrence patterns that were identified how errors occurred at NPPs in the past.

Clinical governance: risks and quality control in radiotherapy

The professions involved in radiotherapy constantly strive to improve quality and to minimize errors and their effects. We are aware of our shortcomings but sometimes are powerless to take corrective action. We have seen that clinical governance requires some change in the medical culture but much has yet to be achieved in the standardization of medical processes. We would gain by sharing experiences of system failures, whether that be by reporting near misses or by disseminating details of litigation cases. In a specialty that depends on human processes and interactions, it is no surprise to find a measurable incidence of human errors. Sometimes this is also related to technological or design deficiencies and we rely too much on human interventions to overcome these. We would like to take positive steps to improve quality, such as those inherent in the new ISO9000 standards, but we are hindered by a variety of constraints--manpower, old technology, pressure to achieve high patient throughput. We need to make decisions for the future development of radiotherapy in the UK. We could settle for a system that is characterized by high throughput and high risk. Hopefully, we will receive the necessary encouragement and resources to strive for high standards of treatment and low risk.