Types Of Human Errors Research Articles

Development of a human reliability analysis framework for nominal human error probability estimate of the TRIGA research reactor in Thailand

Human reliability analysis (HRA) of nuclear research reactors often encounters a lack of human performance data, a challenge that is also faced by the TRIGA reactor of Thailand having no specific full method or human error database for HRA. To overcome this challenge, in 2023, HRA teams from the Korea Atomic Energy Research Institute (KAERI) and the Thailand Institute of Nuclear Technology (TINT) jointly developed an HRA framework for the TRIGA reactor. In the HRA framework development, the HRA practitioners applied KAERI's three main HRA tools, namely 1) the EMpirical data-Based crew Reliability Assessment and Cognitive Error analysis (EMBRACE) method, 2) the Human Reliability data EXtraction (HuREX) database, and 3) the TAsk COMplexity (TACOM) method. The HRA framework covers the overall process including the classification of documents and human error types as well as nominal human error extraction for estimating nominal human error probabilities. According to the results of the first use of the HRA framework on the TRIGA reactor in Thailand, the HRA framework provided an effective way to improve the procedures and systematically identify nominal human errors of actions in the emergency procedures.

Understanding Automation Failure

The implementation of automation in many domains has led to well-documented accidents and incidents, resulting from reduced situation awareness that occurs when operators are out-of-loop (OOTL), automation confusion, and automation interaction difficulties. Wickens coined the term lumberjack effect to summarize the finding that while automation works well most of the time in typical or normal situations, the performance problems that occur in novel or unexpected situations also increase the likelihood of catastrophic errors. Skraaning and Jamieson have criticized the lumberjack effect due to a study in which they failed to find it. I show that this claim is unsupported due to a number of methodological limitations in their study and conceptual errors. They also provide a model of automation failure that fails to clearly delineate the many barriers to accidents that are available, instead emphasizing the ways in which automation can fail technically and different types of human error. An alternate automation failure model is presented that provides a broader socio-technical perspective emphasizing the design features, processes, capabilities, organizational policies, and training that support people in improving system safety when automation fails.

Safety Analysis Using Event Tree Analysis for Multi-Ion Therapy

At the National Institutes for Quantum Science and Technology (QST), a multi-ion therapy using helium, carbon, oxygen, and neon ions has been studied for charged particle therapy with more optimal biological effects. To make multi-ion therapy clinically feasible, a new treatment system was developed to realize the changes of the ion species in each irradiation using the Heavy Ion Medial Accelerator in Chiba (HIMAC). Since radiation therapy is safety-critical, it is necessary to construct a safety system that includes multiple safety barriers in the new treatment system for multi-ion therapy and to perform a safety analysis for the prevention of serious accidents. In this study, we conducted a safety analysis using event tree analysis (ETA) for newly introduced processes in the treatment planning, accelerator, and irradiation system of the multi-ion therapy. ETA is an optimal method to verify multiple safety barriers that are essential for medical safety and to shorten the time for safety analysis by focusing only on the new processes. Through ETA, we clarified the types of malfunctions and human errors that may lead to serious accidents in the new system for multi-ion therapy, and verified whether safety barriers such as interlock systems and human check procedures are sufficient to prevent such malfunctions and human errors. As a result, 6 initial events which may lead to serious accidents were listed in the treatment planning process, 16 initial events were listed in the accelerator system, and 13 initial events were listed in the irradiation system. Among these 35 initial events, 5 cautionary initial events were identified that could lead to serious final events and they had a probability of occurrence higher than 10-4. Meanwhile, the others were all initial events that do not lead to serious accidents, or the initial events that can lead to serious accidents but were considered to have sufficient safety barriers. The safety analysis using ETA successfully identified the system malfunctions and the human errors that can lead to serious accidents, and the multiple safety barriers against them were systematically analyzed. It became clear that the multiple safety barriers were not sufficient for some initial events. We plan to improve the safety barriers for the five cautionary initial events before the start of the clinical trial. Based on these findings, we achieved our objective to conduct a safety analysis for a new treatment system for multi-ion therapy. The safety analysis procedure using ETA proposed by this study will be effective when new systems for radiotherapy are established at QST and other facilities in the future as well.

Errors encountered in the diagnostic pathway: A prospective single-institution study.

Biopsy specimens go through a diagnostic pathway before a pathology report is rendered for the clinician. Errors can occur at any step in this pathway. A 1-year prospective study was conducted at a single academic institution to identify and characterize errors that occurred in the diagnostic pathway from the clinic to the dermatopathology lab. A total of 25 662 specimens were processed and 190 errors were recorded (an error rate of 0.7%). The most common errors were an incorrect biopsy site (n = 65), incorrect data entry of a correct diagnosis (n = 25), and specimen mix-up (n = 23). There were 17 diagnostic errors. Errors most often occurred in the pre-analytical phase (n = 128). The clinician was responsible for 34.2% of errors, the dermatopathologist for 23.7%, and the histotechnician for 18.9%. Slips were the most common type of human error (n = 156). The most common error involved an incorrect biopsy site at the clinical stage. Over two-thirds of errors occurred before the slide reached the dermatopathologist. Diagnostic errors (analytical phase) rarely occurred, and when they did occur, the clinician was most likely to discover the error. Examining and addressing common laboratory errors help to reduce their incidence and lead to quality improvement in dermatopathology.

Father and son are carriers of two different types of human inborn errors of immunity: a case report

IntroductionChronic granulomatous disease (CGD) is an inborn error of immunity (IEI) characterized by recurrent bacterial and fungal infections of skin, airways, liver, brain and bones with the estimated prevalence of 1 in 250,000 live births. CGD can inherited either in an X-linked (allelic variants in the CYBB gene) or autosomal recessive mode (allelic variants in the CYBA, NCF1, NCF2, NCF4, and CYBC1 genes). Wiskott-Aldrich syndrome is an X-linked disorder with an estimated incidence of 1 in 100 000 live male births caused by variants in the WAS gene, characterized by microthrombocytopenia, eczema, recurrent infections, increased risk for autoimmune disease and malignancy. Materials and MethodsIn this case report, we present our experience about two cases of blood relatives diagnosed with different types of human inborn errors of immunity. Genetic analysis of CYBB gene in 2007 was performed by Sanger sequencing and of WAS gene in 2022 by next generation amplicon sequencing. All subjects consented to the study. ResultsThe first case was a 15-year-old male (1992 y.o.b., proband) who was diagnosed as X-linked CGD patient in 2007 due to his clinical history and hemizygote allelic variant in the CYBB gene (NM_000397.4: c.484–1G>T, COSV101059810). The second case was a 2-month-old boy (biological son of proband) who was hospitalized in 2022 due to microthrombocytopenia, low platelet volume, cytomegalovirus infection, mild anemia. Genetic analysis revealed in the DNA sample of the second case the hemizygote allelic variant in the WAS gene (NM_000377.3: c.777 +3_777+6del GAGT). Genetic testing didn’t reveal such variant in the DNA sample of the proband's wife, that's why this variant was classified as “de novo”. ConclusionInborn errors of immunity (IEI) present clinically as increased susceptibility to infections, autoimmunity, autoinflammatory diseases, allergy, bone marrow failure, and/or malignancy. There are now a total of 485 IEI, which are segregating to 10 groups of disorders into overlapping phenotypes. Despite the fact that IEI are rare diseases, we have shown that even in one family two different types of disorders can occur. In our case the second IEI was occur due to spontaneously alterations during the process of DNA replication during cell division.

How do medication errors occur in the nursing communication process? Investigating the relationship between error types and error factors.

Human error types and error factors are two important elements of error analysis. Understanding the relationship between them can contribute to new case analyses, the tendency of error occurrence statistics, error factor identification, and prevention of error recurrence. To provide evidence and guidance for the prevention and improvement of medication communication errors by quantitatively exploring the relationship between error types and error factors. Data were collected on self-reported errors in the medication administration process by nurses in all departments of three cooperative medical institutions, and an error sheet of specified style was adopted. Error types were determined by the systematic human error reduction and prediction approach method and human cognition processes. Error factors were extracted using the root cause analysis combined with Berlo's communication model, and the relationship between error types and error factors was quantitatively studied using the partial least-squares regression method. After a one-by-one analysis of 303 error cases, the communication errors occurring in the nursing medication process could be explained by six error types and 12 error factors. In addition, 20 correlation patterns between the error types and error factors were quantitatively obtained, and their path coefficient distributions ranged from 0.088 to 0.467. The results of this study may provide reference to understand errors and establish countermeasures from the statistics of error occurrence trends, extract error factors related to error types and determine key error factors.

Quality and Safety in Healthcare, Part LXXXIII: The Culture of Safety in High Reliability Organizations.

A safety culture encourages the reporting of mistakes so that all can learn from them and remedy underlying system problems. However, errors will only be reported in a culture in which most types of common human errors are not punished because all humans make errors, and usually there are underlying system problems contributing to this. All healthcare errors must be viewed partly as opportunities to improve. A safety culture includes good leadership, communication, learning, collaboration, mindfulness, medicine that is based on evidence and best practice, and care that is centered on the patient.

Human errors and factors that influence patient safety in the pre-hospital emergency care setting: Perspectives of South African emergency care practitioners.

BackgroundDelivering pre-hospital emergency care has the potential to be hazardous. Despite this, little is known about the factors that precipitate human errors and influence patient safety in the pre-hospital care setting, in contrast to in-hospital care. Similarly, limited report on patient safety and human error issues in the pre-hospital emergency care setting exist in South Africa.AimThis study investigated the perspectives of emergency care personnel (ECP) in South Africa on the types of human errors and factors that precipitate human errors that influence patient safety in the pre-hospital emergency care setting in South Africa.SettingThis study was conducted in the pre-hospital emergency care environment in South Africa.MethodsThis research was designed as an exploratory study that made use of a semi-structured questionnaire administered to 2,000 emergency care personnel.ResultsA response rate of 76% was obtained. According to the participants, errors relating to poor judgement, poor skill or knowledge, fatigue, and communication, and individual error are common during pre-hospital care. Inadequate equipment, environmental factors, and personal safety concerns were reported as some of the factors that influence patient safety in the pre-hospital emergency care setting.ConclusionImplementation of strategies that enhances education and training, clinical skill development, teamwork skills, fatigue management, and leadership skills can help prevent some of the errors identified in this study.ContributionThis study identifies the types of human errors, and factors that precipitate human errors that influence patient safety in the pre-hospital emergency care setting in South Africa.

Micro-Behavioral Accidental Click Detection System for Preventing Slip-Based Human Error.

Accidentally clicking on a link is a type of human error known as a slip in which a user unintentionally performs an unintended task. The risk magnitude is the probability of occurrences of such error with a possible substantial effect to which even experienced individuals are susceptible. Phishing attacks take advantage of slip-based human error by attacking psychological aspects of the users that lead to unintentionally clicking on phishing links. Such actions may lead to installing tracking software, downloading malware or viruses, or stealing private, sensitive information, to list a few. Therefore, a system is needed that detects whether a click on a link is intentional or unintentional and, if unintentional, can then prevent it. This paper proposes a micro-behavioral accidental click detection system (ACDS) to prevent slip-based human error. A within-subject-based experiment was conducted with 20 participants to test the potential of the proposed system. The results reveal the statistical significance between the two cases of intentional vs. unintentional clicks using a smartphone. Random tree, random forest, and support vector machine classifiers were used, exhibiting 82.6%, 87.2%, and 91.6% accuracy in detecting unintentional clicks, respectively.

Testing and practical validation of an individual safety performance assessment methodology – the SSP System

The “Safety Score Permit” (SSP) is a new tool that focuses on behaviour and is based on a point system which allows individual performance’s tracking, thus encouraging safe actions. The present study aims at verifying the applicability and practical validation of the first SSP version; the ultimate goal is to evaluate its coverage within different industrial contexts and identify limitations and opportunities for improvement. A pilot implementation was conducted in three large companies, presented as three case studies. The records of safety behaviour observations (SBO) of each case were analysed to verify if all the “observed deviations” fitted into the classes and subclasses typified in the system. Although the study basis was the same in all three cases, in two of them the research was based on existing SBO records collected in 2019, whilst in the 3rd case there was a much higher interaction throughout the work. In this case, the process was started from scratch, including the SBO procedure, its monitoring and subsequent data analysis, to create the necessary conditions for the implementation of the full system. The results obtained revealed that, in general, the SSP platform has the ability to cover most deviations identified in an organization. The system has the potential to become a useful and transparent tool to monitor employees’ safety performance at all hierarchical levels; it also helps to identify weaknesses in the companies’ OHS processes. This work was essentially exploratory but it shed light on how to improve the system further and also unveiled new opportunities. A key issue to enhance SSP as a management tool is to expand its scope to all types of human errors, thus offering better support to strategic OHS decisions.

Application of a quantitative human performance model to the operational procedure design of a fuel storage pool cooling system

Probabilistic safety analyses and Human Reliability Analysis have a potential contribution for designing new systems. For this, it is essential to develop models that are able to feed analyses at the design stage and to bring results that can be used in decision-making. This reinforces the need to develop quantitative techniques for performing human reliability still in the design phase of complex systems – a stage with little information available for Human Reliability Analysis. Currently, one can find publications of this kind for equipment reliability but not for human reliability. This paper presents a technique for human performance analysis that can be used in system design phase. This technique is based on the use of different information sources to obtain probability estimates of the various human error types that may occur during a specific action, and to estimate human error probabilities of generic actions. Thus, considering this model and a methodology for the early quantitative consideration of reliability in the design of complex systems, this paper presents the conception of an operational procedure for a Fuel Storage Pool Cooling System for cooling the spent fuel of a pressurized nuclear reactor, by configuring the human factors without changing the equipment preset for the system.

The mediating effect of workers’ situation awareness on the relationship between work-related factors and human error: a path analysis approach

Situation awareness is the main reason behind different patterns of unsafe behavior among workers and can play a mediating role in the relationship between predictive situational variables and human error. This questionnaire-based study carried out with Iranian workers investigated the direct and indirect effects of work pressure, mental workload, human–systems interaction and environmental distractions on three types of human error (i.e., slips, lapses and mistakes). The results of path analysis showed that, based on model fit indexes, the model is appropriately fit (χ 2 / df = 3, comparative fit index = 099, Tucker–Lewis index = 0.99, root mean square error of approximation = 026). It was also observed that the effects of four independent variables on all three types of human error are indirect and mediated by situation awareness. Consequently, it is confirmed that situation awareness plays a key role in the occurrence of human error and is a sharp-end causal factor for human error in industrial workplaces.

Interpretations of Human Error in Aviation

The author attempts to describe whether the human errors in aviation could be taken out of the system, or otherwise they are useful and prevention methods could be based on them. The human error, as parts of safety philosophy, are examined by many theories like the Reason theory, the SHEL(L) theory, and the SRK theory. Although, approaches and perspectives from which they circumscribe most of the frequent types of human error are different theories and conclusions have some similarities. One common element of them is, that they could not tell whether human error is acceptable or unacceptable. So as to answer this question the author points out the difference between old fashioned and modern safety philosophies.

SHERPA기법을 이용한 항공기 착륙상황에서 발생 가능한 인적오류 예측

This study aims to examine probable human errors when landing an airplane by the use of SHERPA(systematic human error reduction and prediction approach) and propose methods for preventing the predictive human errors. It has been reported that human errors are concerned with a lot of accidents or incidents of an airplane. It is significant to predict presumable human errors, particularly in the operation mode of human-automation interaction, and attempt to reduce the likelihood of predicted human error. By referring to task procedures and interviewing domain experts, we analyzed airplane landing task by using HTA(hierarchical task analysis) method. In total, 6 sub-tasks and 19 operations were identified from the task analysis. SHERPA method was used for predicting probable human error types for each task. As a result, we identified 31 human errors and predicted their occurrence probability and criticality. Based on them, we suggested a set of methods for minimizing the probability of the predicted human errors. From this study, it can be said that SHERPA can be effectively used for predicting probable human error types in the context of human-automation interaction needed for navigating an airplane.

Assessment of Knowledge About Patient Safety Concepts Among Medical and Pharmacy Students.

Patient safety is a central principle of healthcare professional practice that requires a significant consideration within the teaching curricula; however, there is a lack of special courses that focus on patient safety concepts in an integrated way in many countries. This study aims to assess the knowledge of medical and pharmacy students regarding patient safety concepts. A cross-sectional study was conducted at Alfaisal University during the 2018-2019 school year. A survey consisting of 15 questions was designed with the help of the quality and patient safety department at King Faisal Specialist Hospital and Research Centre, Riyadh (KFSHRC). The survey was validated and then electronically distributed to all students enrolled in the College of Medicine and College of Pharmacy. A total of 304 (22%) of 1368 students completed the survey. The survey revealed that 51% of students had an acceptable understanding of the types of human error; however, 53% of students had little knowledge about the factors that lead to these errors and 61% did not know how to report an error. Many students (41%) reported being directly involved in an unsafe situation that may cause patient harm, such as a healthcare-related error, adverse event, or inconsistent care. Most students (90%) agreed that hiding errors to avoid further implications is unethical and reporting errors is the responsibility of every healthcare provider. Most Alfaisal University students understand the significance of patient safety education and understand the types of human errors, yet the causes of errors and the protocols for reporting them were not well understood by most students.

Human error in motorcycle crashes: A methodology based on in-depth data to identify the skills needed and support training interventions for safe riding

Objective Human error by either rider or other vehicle driver is the primary contributing factor in crashes involving powered-two-wheelers. A human-factor-based crash analysis methodology is key to enhancing the road safety effectiveness of rider training interventions. Our aim is to define a methodology that uses in-depth data to identify the skills needed by riders in the highest risk crash configurations to reduce casualty rates. Methods The methodology is illustrated through a case study using in-depth data of 803 powered-two-wheeler crashes. Seven types of high-risk crash configuration based on pre-crash trajectories of the road-users involved were considered to investigate the human errors as crash contributors. Primary crash contributing factor, evasive maneuvers performed, horizontal roadway alignment and speed-related factors were identified, along with the most frequent crash configurations and those with the greatest risk of severe injury. Results Straight Crossing Path/Lateral Direction was the most frequent crash configuration and Turn Across Path/Opposing Direction was identified as that with the highest risk of serious injury. Multi-vehicle crashes cannot be considered as a homogenous category of crashes to which the same human failure is attributed, as different interactions between motorcyclists and other road users are associated with both different types of human error and different rider reactions. Human error in multiple-vehicle crashes differed between those configurations related to crossroads and those related to rear-end and head-end crashes. Both single-vehicle crashes and multi-vehicle head-on crashes frequently occur along curves. The involved collision avoidance maneuvers of the riders differed significantly among the highest risk crash configurations. The most relevant lack of skills are identified and linked to their most representative context. In most cases a combination of different skills was required simultaneously to avoid the crash. Conclusions The results contribute to understand the motorcyclists’ responses in high-risk crash scenarios. The findings underline the need to group accident cases, beyond the usual single-vehicle versus multi-vehicle collision approach. The different interactions with other road users should be considered to identify the competencies of the motorcyclists needed to reduce crash risks. Our methodology can be applied to increase the motorcyclists’ safety by supporting preventive actions based on riders’ training and eventually ADAS design.

Narrative Analysis of Runway Incursion Reports in the National Transportation Safety Board Database To Identify Contributing

A runway incursion occurs when an aircraft, ground vehicle, or a pedestrian is incorrectly present on the runway. This incorrect presence can lead to a collision resulting in fatal injuries and aircraft damage. Despite the aviation community’s measures to reduce incursions, they continue increasing. Most runway incursions are a result of human error. Our limited knowledge of these human errors and their causes is hindering our ability to reduce runway incursions. While previous researchers have analyzed past runway incursions to identify types of human error, we still know little about the causes of these errors. The narratives in the NTSB database often provide detailed information to identify human errors and their causes. In this paper, we analyze the narratives of runway incursion reports in the NTSB database. We use task analysis to map human error to tasks they perform, and map the causes of these errors to the error itself.

A day in the life of frontline manufacturing personnel: A diary-based safety study

Recorded incidences of work-related illness and injury within the manufacturing sector remain significantly high, therefore, an awareness of the aetiology of accidents remains integral to any realistic prospect of safety improvement interventions within this complex industry. The epistemological stance adopted in safety behaviour development in research design and execution has largely focused on empirical outcome-based studies. Using personalised individual diaries to record real time data of safety-related events, including social cognitive contextual details, this study, for the first time qualitatively explores employee recorded incidents, permitting the identification of perceived latent conditions belying cognitive errors. The study revealed the most frequently occurring incident types were unsafe acts (38%) followed by unsafe conditions (28%), with a greater proportion of near misses (N = 46) in comparison to actual accidents (N = 13). Also apparent were inconsistencies in formal and informal reporting processes. Skill based errors were the most prevalent recorded human error type associated with distraction, alongside incompatible work environments. Violations were evident, to a lesser degree of recordable incidents. Across all human error types, qualitative accounts of safety climate concepts including leader violations and quality of leadership were described. The study thus made possible the capture of day-to-day safety behaviours and conditions, illuminating new perspectives on meaningful issues at both individual and systems levels. Adopting a systematically tailored approach to the exploration of suboptimal safety behaviour aetiology, there is a greater likelihood of knowledge acquisition of incidents or symptoms at an organisational level, which are then equipped to reflexively respond with a tailored address of these issues ‘in situ’.

HEALTHCARE QUALITY AND NARRATIVE MEDICINE

Healthcare has been one of the most vital endeavors in human life during the entire history of humanity. In the past two millennia, all efforts and expertise are put into healthcare in order to maintain human beings in healthy condition. While the science and technology in medical field has advanced incredibly, some serious issues remain as problems in healthcare activities that need attention. Two issues that have been researched and discussed in the literature during the past century are quality and ethical problems in healthcare. Parallel to these issues is a new branch of research, called medical humanities, which attempts to emphasize the subjective experience of patients within the objective and scientific world of medicine, where literature plays a major role to influence and enrich medical practice. In this paper, we try to summarize basic types of human errors, medical malpractices, causes of quality problems, and ethical issues in healthcare systems. We also try to present our views on healthcare quality and ethics and their relations to narrative medicine with an attempt to discourse the prospects of improving healthcare quality through narrative medicine. Keywords: Healthcare quality, healthcare errors, medical ethics, medical humanities, narrative medicine

Human errors in traffic accidents: differences between car drivers and motorcyclists’ experience

Traffic accidents have become one of the main causes of death in Indonesia. The biggest contributor to traffic accidents are motorcyclists. According to police records, human error plays a major role in the occurrence of accidents. The aim of this study is to analyze the potential types of human error that contribute to traffic accidents, as well as the psychological factors that underlie traffic accidents experienced by car drivers and motorcyclists. Data was collected by interviewing five car drivers and five motorcyclists. Results show that the car drivers tend to perform a type of human error which is classified as lapses, while the motorcyclists tend to do an error of slips. For psychological factors that underlie traffic accident, results show that both car drivers and motorcyclists made recognition errors, i.e. did not estimate distance, time, and speed. They also made decision errors, i.e. did not avoid the situation immediately, and performance errors, i.e. a motorcyclist stepped on the gas pedal by mistake. Other errors done by the car drivers were being sleepy and drunk, whereas other errors done by motorcyclists were not having a riding license and feeling tired. The implication of this study is to make the drivers/riders aware of the importance of cognitive aspects in driving.