Lack Of Situational Awareness Research Articles

한국 경호원의 휴먼팩터 유발 요인에 관한 분석

This study was conducted to derive the factors behind potential human errors among Korean bodyguards and devise response strategies accordingly. For Research Project 1 (identification of human errors according to the cognitive and psychological characteristics of security guards), two interviews were conducted with 10 experts, and for Research Project 2 (identification of factors causing human errors according to behavioral and psychological characteristics of security guards), VTA technique and Multiple case analysis was conducted using the M-SHEL model. Research task 3 (deriving human factor factors of Korean bodyguards and suggesting coping strategies) was conducted using complex research methods and grounded theory approaches. As a result of the study, the human factors of security guards based on their cognitive psychological characteristics and risk normalization tendency were lack of security personnel (lack of professional spirit, lack of motivation), complacent attitude (underestimation of risk), and control failure (lack of situational awareness, VIP protocol). (First of all), etc., and the human factors of security guards based on cognitive and psychological characteristics behavior and behavioral psychological characteristics are formal and familiar work performance (lack of motivation), complacent attitude (underestimation of risk), lack of safety awareness and situational awareness (lack of motivation), etc. Familiarity with work, VIP protocol priority), etc. Through these results, it was concluded that the human factor of security guards can be reduced by strengthening the security guard's professional spirit, increasing motivation, strengthening safety awareness and situational awareness, and education and training to improve risk awareness and control ability.

Key Insights from Preflight Planning for Safety Improvement in General Aviation: A Systematic Literature Review

This study highlights the disproportionate number of fatal and non-fatal accidents in general aviation (GA) compared to airline carriers, emphasizing the need to investigate the contributing factors to these incidents. It identifies poor decision-making and a lack of situational awareness as key issues and presents a systematic literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method to analyze preflight information used by GA pilots. The findings underscore the significance of operational factors in ensuring a successful flight and suggest modifications to pilot license renewal processes, with an emphasis on the adoption of digital preflight tools. A new theoretical framework based on the operational factors identified is also introduced, which could serve as a foundation for future studies and interventions aimed at enhancing safety in general aviation.

Recognizing the situation awareness of forklift operators based on EEG techniques in a field experiment.

Lack of situation awareness (SA) is the primary cause of human errors when operating forklifts, so determining the SA level of the forklift operator is crucial to the safety of forklift operations. An EEG recognition approach of forklift operator SA in actual settings was presented in order to address the issues with invasiveness, subjectivity, and intermittency of existing measuring methods. In this paper, we conducted a field experiment that mimicked a typical forklift operation scenario to verify the differences in EEG states of forklift operators with different SA levels and investigate the correlation of multi-band combination features of each brain region of forklift operators with SA. Based on the sensitive EEG combination indexes, Support Vector Mechanism was used to construct a forklift operator SA recognition model. The results revealed that there were differences between forklift operators with high and low SA in the θ, α, and β frequency bands in zones F, C, P, and O; combined EEG indicators θ/β, (α + θ)/(α + β), and θ/(α + β) in zones F, P, and C were significantly correlated with SA; the recognition accuracy of the model reached 88.64% in the case of combined EEG indicators of zones C & F & P as input. It could provide a reference for SA measurement, contributing to the improvement of SA.

Hyperventilation in cardiac arrest—a systematic review and narrative synthesis

Background: Resuscitation guidelines recommend delivering ventilations at a rate of 10 per minute. However, hyperventilation is commonly reported during out-of-hospital cardiac arrest resuscitation efforts, and the impact of this on patient outcomes is unclear. This review explores the reported rates, causes and patient outcomes of hyperventilation in the management of out-of-hospital cardiac arrest. Methods: A systematic literature review with a narrative synthesis of three databases was carried out. Findings: Thirteen papers met the eligibility criteria. These showed that ventilations were consistently delivered at a higher rate and tidal volume than are internationally recommended. Hyperventilation can occur because of clinician stress, a lack of situational awareness and a focus on other clinical interventions as well as poor leadership. Conclusion: Hyperventilation is common during cardiac arrest management. Currently available human data do not produce sufficient evidence to favour any ventilation strategy; however, a harmful upper limit will exist. This review found no human randomised control studies examining how ventilation rate, tidal volume or pressure affect patient outcomes and this warrants further research.

An Approach for Measuring The Effects of Augmented Reality on Human Performance in Maritime Navigation

A lack of Situation Awareness in maritime navigation has been shown to be a reoccurring contributory cause of vessel collisions at sea. Vessel navigation and operational tasks have progressively moved towards screen-based interactions and monitoring, leading to increased navigator Head-Down Time and decreased navigator performance. Augmented Reality enables new and different opportunities to display operational data, which may reduce Head-Down Time and better support navigator Situation Awareness. However, research and development of Augmented Reality solutions in maritime operations are still in the preliminary stages. This paper presents a multidisciplinary approach towards developing and testing Augmented Reality solutions for maritime applications. We describe a methodology for investigating the effects of Augmented Reality on human performance during maritime navigation scenarios and how this data feeds back in an iterative design and development process using a user-centred approach for maritime digitalization and new technology initiatives.

An Eye Tracking Based Framework for Safety Improvement of Offshore Operations.

Offshore drilling operations consist of complex and high-risk processes. Lack of situational awareness in drilling operations has become an important human factor issue that causes safety accidents. Prolonged work shifts and fatigue are some of the crucial issues that impact performance. Eye tracking technology can be used to distinguish the degree of awareness or alertness of participants that might be related to fatigue or onsite distractions. Oculomotor activity can be used to obtain visual cues that can quantify the drilling operators' situational awareness that might enable us to develop warning alarms to alert the driller. Such systems can help reduce accidents and save non-productive time. In this paper, eye movement char-acteristics were investigated to differentiate the situational awareness between a representa-tive expert and a group of novices using a scenario-based Virtual Reality Drilling Simulator. Significant visual oculomotor activity differences were identified between the expert and the novices that indicate an eye-tracking based system can detect the distraction and alert-ness exhibited by the workers. Results show promise on developing a framework which implements a real-time eye tracking technology in various drilling operations at drilling rigs and Real Time Operation Centers to improve process safety.

The Effects of Auditory Working Memory Task on Situation Awareness in Complex Dynamic Environments: An Eye-movement Study.

This study investigated the effect of auditory working memory task on situation awareness (SA) and eye-movement patterns in complex dynamic environments. Many human errors in aviation are caused by a lack of SA, and distraction from auditory secondary tasks is a serious threat to SA. However, it remains unclear how auditory working memory tasks affect SA and eye-movement patterns. Participants (n = 28) were randomly allocated to two groups and received different periods of visual search training (short versus long). They subsequently completed a situation awareness measurement task in three auditory secondary task conditions (without secondary task, auditory calculation task, and auditory 2-back task). Eye-movement data were collected during the situation awareness measurement task. The auditory 2-back task significantly reduced overall SA, Level 1 SA, dwell times, and total percentage of fixation time on task-related areas of interests in the SA measurement task. Overall SA and Level 3 SA were not reduced by the auditory 2-back task in individuals in the longer visual search training time condition. Auditory working memory load impairs SA in the perception and projection stage; however, greater experience can overcome impairment of SA in the projection stage. This study provided possible approaches to preventing loss of SA: (1) improving crew members' communication skills to ensure the accurate and clear transmission of information, reducing the difficulty of processing information, and (2) providing targeted cognitive training tailored to each pilot's level of experience.

인공지능(AI)과 Chat GPT, 부패에 관한 소고

This study discusses corruption and moral hazard arising from the use of artificial intelligence(AI) and Chat GPT and presents implications. In this study, 1. The daily use of AI and Chat GPT is 1) Lack of situational awareness and thinking, 2) Absence of appropriate ethical norms and social codes, 3) Problems with shifting consciousness, 4) Concentration of economic and technological utility, 5) Deepening dependence on AI. 2. Problems in the information processing process of AI and Chat GPT were 1) lack of transparency and autonomy of AI, 2) value judgment and bias of Chat GPT algorithm, 3) intervention and distortion of decision-making, 4) possibility of copyright infringement, and 5) safety of use and services. 3. Problems in the information distribution process of AI and Chat GPT are 1) limitations of the Chat GPT algorithm and information distortion, 2) information asymmetry and centralization, 3) inaccuracy and uncertainty of information, 4) misuse of information or data, 5) Information security and information leakage occurred. The implications of this study are as follows. First, education and promotion of AI and Chat GPT include 1) Composition of public and private cooperation governance, 2) Development of national campaigns, 3) Found and service of AI and Chat GPT, 4) establishment of ethical norms and manners for AI and Chat GPT, 5) Social coding of AI ethics and manners. Second, the institutional devices for AI and Chat GPT are 1) Setting the regulatory scope and level to secure transparency and autonomy, 2) Monitoring of bias in information by public and private sectors, 3) Management and supervision of the information collection process, 4) Establishment of an institutional device to prevent AI from intervening in decision-making and preventing distortion, 5) Establishment of standards and systems to ensure the safety of information processing. Third, normative device for AI and Chat GPT as follows. The contents are: 1) Discussion and search for normative standards, 2) Exploring ways to resolve the centralization of information, 3) securing the clarity and reliability of information, 4) designing information security and leakage prevention programs, 5) Monitoring to prevent misuse and abuse of information.data.

The role of human factors in aviation ground operation-related accidents/incidents: A human error analysis approach

Aviation is a complex socio-technical system with interconnected and interdependent subsystems, such as flight operations, air traffic control, aircraft maintenance and ground operations. However, safety and risk research has not paid, thus far, adequate attention to all subsystems, resulting in possibly undetected or underestimated risks. This study focuses on Ground Operations (GO) as a subsystem and analyses the role of human factors in ground operations related accidents and incidents. 87 accident and incident reports (from 2000 to 2020) were analysed in three stages, using the Human Factors Dirty Dozen (HF DD) Model and the Human Factors Analysis and Classification Scheme (HFACS) as a basis for the third stage, a systematic thematic analysis. The findings indicate that lack of situational awareness and failure to follow prescribed procedures are the main causal and contributing factors in GO-related accidents and incidents. Three operational actions were identified as most critical: aircraft pushback/towing, aircraft arrival and departure, and aircraft weight and balance. An agenda for future research and recommendations for industry corrective action are proposed.

Analysis of Physical Workload and Situational Awareness at the Apron Movement Control (AMC) Unit at Husein Sastranegara International Airport Bandung

Efforts to develop human resources in line with the company's vision and mission are not an easy job, companies are required to be able to prepare a workforce that is able to carry out tasks in work effectively and efficiently. Obstacles that often occur in a company in efforts to develop human resources are high physical workload or workload and lack of situational awareness. This research uses a type of research with a qualitative descriptive method. To be able to get answers from the research, the researcher made a research design design. Qualitative research is research that is used to investigate, find, describe, and explain the quality of influences that cannot be explained, measured or described through a quantitative approach. The results of the study show that the physical workload of the AMC unit at Husein Sastranegara Airport in Bandung is very high due to the very wide coverage of the supervisory area, as well as the great responsibility in supervising and controlling all movements on the air side, with a large number of personnel. experienced a shortage of officers/executors as field workers, where the AMC unit only had 2 officers/executors, therefore with this great responsibility the workload on the AMC unit was also very high. Regarding the condition and form, the level of Situational awareness possessed by AMC officers is already at level 3, because officers can function themselves in the right conditions and at the right time in the surrounding environment in an effective way

Role of ethnicity in high-level obstetric clinical incidents: a review of cases from a large UK NHS maternity unit

IntroductionWomen from ethnic minority groups are at more risk of adverse outcomes in pregnancy compared with those from white British groups; suboptimal care may contribute to this increased risk. This...

Probability-based extensive quantitative risk analysis: collision and grounding case studies for bulk carrier and general cargo ships

ABSTRACT In this study, the risk of collision and grounding accidents on bulk carrier and general cargo ships was investigated. A comprehensive risk analysis consisting of past accident reports, fault tree analysis (FTA) and Cut sets importance measure (CS-I) methods was carried out. The failures effective in the occurrence of collision and grounding accidents were determined by examining past accident reports. In the study, the probability for each failure was derived by using real accident data. Using FTA, various potential accident occurrence combinations/scenarios, also known as minimal cut sets (MCSs), for both accident types were obtained. In addition, prioritization was conducted for the MCSs of both types of accidents using CS-I sensitivity analyses. The faults that increase the risk of collision accidents the most were found to be interpretation failure of the Convention on the International Regulations for Preventing Collisions (COLREG) and lack of situational awareness. In addition, the top failures that lead to groundings were determined to be lack of communication in bridge resource management (BRM), fatigue/sleeplessness and inappropriate voyage plan. Recommendations are made for eliminating potential risk factors, preventing the recurrence of such accidents and establishing safer maritime transport.

Pediatric Patient Safety: Shared Learning to Improve Patient Outcomes.

Two decades ago, the seminal Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine) report To Err Is Human: Building a Safer Health System first highlighted the influence of poorly designed health care delivery systems and suboptimal processes as contributors to patient safety.1 Substantial progress has occurred since then, including creation of a federally mandated Child Health Patient Safety Organization,2 which uses a standardized taxonomy for patient safety events, contributory factors, and severity of harm,3 with shared learning by dissemination of reports to individual institutions and to the public.4 In this issue of Pediatrics, Burrus et al analyze and report on 4 years of serious safety events (SSEs) from 44 Child Health Patient Safety Organization–participating hospitals regarding the types of safety events, severity of harm, and contributory factors.5 Their results underscore the overall improvement in pediatric safety in these institutions during the study period as demonstrated by a downward trend in SSEs from 0.71 to 0.41 per 10 000 adjusted patient days. The strengths of this study are the learnings from a collaborative, which can be disseminated publicly, the spectrum of harm among the reported SSEs (with one-fifth of SSEs having the highest severity defined as death or permanent harm), and the identification of more important contributory factors, such as lack of situational awareness. However, the study results also reveal there is still much to be done to mitigate pediatric patient harm.Organizations must continue to implement strategies to eliminate harm related to procedures (eg, retained foreign objects, wrong procedures). Recently there has been controversy regarding the pursuit of zero harm because it might lead to provider burnout, which can lead to harm and increased health care costs.6 Regardless, as stated by the legendary football coach Vince Lombardi, “Perfection is not attainable, but if we chase perfection we can catch excellence.” Hospitals need to remain laser-focused on all causes of preventable patient harm, especially those resulting from procedures, medications, and other products and devices. There are also important lessons to be learned from non-SSEs that were excluded from this analysis.Furthermore, patient safety needs to be understood in the context of the care setting. Several studies have revealed that certain settings such as emergency departments, operating rooms, and ICUs are more prone to safety events. Indeed, several reports from the federally supported pediatric research network Pediatric Emergency Care Applied Research Network highlight the types, contributory factors, and severity of harm in the context of pediatric emergency care.7–10 Finally, as the number of procedural events and medication errors decrease, the hidden impact of missed, delayed, or wrong diagnosis was justifiably identified in the Burrus et al article. Diagnostic errors have been considered for a long time as the “blind spot” in patient safety and the National Academies of Sciences, Engineering, and Medicine report Improving Diagnosis in Health Care highlighted that most individuals will experience at least 1 diagnostic error in their lifetime, sometimes with devastating consequences.11 Similar to other safety events, diagnostic safety needs standardized taxonomy, validated and accepted definitions, and robust study designs, including prospective, multicenter studies to understand the epidemiology, contributory factors, severity of harm, and impact of interventions to mitigate harms.12 Ultimately, patient safety (avoidance of negative outcome) and quality (achievement of positive outcome) need to be at the center of all health care services. The imperative to support multidimensional approaches to reduce patient harm, including research, education, training, and policy, has never been greater.

Factors Related to Serious Safety Events in a Children's Hospital Patient Safety Collaborative.

Serious safety events (SSEs) occur infrequently at individual hospitals, making it difficult to establish trends to improve patient care. Patient safety organizations, such as the Child Health Patient Safety Organization (CHILDPSO), can identify trends and support learning across children's hospitals. We aim to describe longitudinal trends in SSE rates among CHILDPSO member hospitals and describe their sources of harm. SSEs from 44 children's hospitals were assigned severity and reported to CHILDPSO from January 1, 2015, to December 31, 2018. SSEs were classified into groups and subgroups based on analysis. Events were then tagged with up to 3 contributing factors. Subgroups with <5 events were excluded. There were 22.5 million adjusted patient days included. The 12-month rolling average SSE rate per 10 000 adjusted patient days decreased from 0.71 to 0.41 (P < .001). There were 830 SSEs reported to CHILDPSO. The median hospital volume of SSEs was 12 events (interquartile range: 6-23), or ∼3 SSEs per year. Of the 830 events, 21.0% were high severity (SSE 1-3) and approximately two-thirds (67.0%, n = 610) were patient care management events, including subgroups of missed, delayed, or wrong diagnosis or treatment; medication errors; and suboptimal care coordination. The most common contributing factor was lack of situational awareness (17.9%, n = 382), which contributed to 1 in 5 (20%) high-severity SSEs. Hospitals sharing SSE data through CHILDPSO have seen a decrease in SSEs. Patient care management was the most frequently seen. Future work should focus on investigation of contributing factors and risk mitigation strategies.

English

Introduction: Hundreds of millions of people practice winter sports worldwide. Alpine skiing and snowboarding are associated with a possible risk of injury. There are at least three important factors that can affect safety in wilderness activities (environmental factors, technical factors and human factors). Awareness of human factors would allow us to reduce the risk in winter sports. Material and method: The objective of this study is to find out, through a self-explanatory cross-sectional personal survey, what and how human factors are involved in alpine skiing and snowboarding accidents. Results: 219 surveys were carried out of a total of 3,911 patients attended at the different health care points. The highest percentage of respondents related their accident to distraction or complacency, both in 72.2% of the respondents. Other factors that were pointed out by more than 50% were; lack of knowledge (60.4%), lack of following the norms (58.5%), fatigue (57.5%), lack of situational awareness (57%) and stress with (53.8% of the respondents). Conclusions: By identifying these most frequent human factors during downhill skiing and snowboarding, actions can be taken to prevent or contain human error.

3-D Object Tracking in Panoramic Video and LiDAR for Radiological Source–Object Attribution and Improved Source Detection

Networked detector systems can be deployed in urban environments to aid in the detection and localization of radiological and/or nuclear material. However, effectively responding to and interpreting a radiological alarm using spectroscopic data alone may be hampered by a lack of situational awareness, particularly in complex environments. This study investigates the use of Light Detection and Ranging (LiDAR) and streaming video to enable real-time object detection and tracking, and the fusion of this tracking information with radiological data for the purposes of enhanced situational awareness and increased detection sensitivity. This work presents an object detection, tracking, and novel source–object attribution analysis that is capable of operating in real time. By implementing this analysis pipeline on a custom-developed system that comprises a static 2 in. $\times 4$ in. $\times16$ in. NaI(Tl) detector colocated with a 64-beam LiDAR and four monocular cameras, we demonstrate the ability to accurately correlate trajectories from tracked objects to spectroscopic gamma-ray data in real time and use physics-based models to reliably discriminate between source-carrying and nonsource-carrying objects. In this work, we describe our approach in detail and present a quantitative performance assessment that characterizes the source–object attribution capabilities of both video and LiDAR. Additionally, we demonstrate the ability to simultaneously track pedestrians and vehicles in a mock urban environment and use this tracking information to improve both detection sensitivity and situational awareness using our contextual-radiological data fusion methodology.

In-situ simulations for COVID-19: a safety II approach towards resilient performance

BackgroundCOVID-19 has taken the world by surprise; even the most sophisticated healthcare systems have been unable to cope with the volume of patients and lack of resources. Yet the gradual spread of the virus in Lebanon has allowed healthcare facilities critical time to prepare. Simulation is the most practical avenue not only for preparing the staff but also for troubleshooting system’s latent safety threats (LSTs) and for understanding these challenges via Hollnagel’s safety I–II approaches.MethodsThis is a quality improvement initiative: daily in situ simulations were conducted across various departments at the American University of Beirut Medical Center (AUBMC), a tertiary medical care center in Beirut, Lebanon. These simulations took place in the hospital with native multidisciplinary teams of 3–5 members followed by debriefing with good judgment using the modified PEARLS (Promoting Excellence and Reflective Learning in Simulation) for systems integration. All participants completed the simulation effectiveness tool (SET-M) to assess the simulation. Debriefings were analyzed qualitatively for content based on the Safety Model and LST identification, and the SET-Ms were analyzed quantitatively.ResultsTwenty-two simulations have been conducted with 131 participants. SET-M results showed that the majority (78–87%) strongly agreed to the effectiveness of the intervention. We were able to glean several clinical and human factor safety I–II components and LSTs such as overall lack of preparedness and awareness of donning/doffing of personal protective equipment (PPE), delayed response time, lack of experience in rapid sequence intubation, inability to timely and effectively assign roles, and lack of situational awareness. On the other hand, teams quickly recognized the patient’s clinical status and often communicated effectively.ConclusionThis intervention allowed us to detect previously unrecognized LSTs, prepare our personnel, and offer crucial practical hands-on experience for an unprecedented healthcare crisis.

BEZPIECZEŃSTWO W RUCHU DROGOWYM – PIESI JAKO NIECHRONIENI UCZESTNICY RUCHU DROGOWEGO

Cel badań. Celem przeprowadzonych badań było wykazanie obszarów ochrony pieszych pod względem prawnym i technicznym oraz tego, jaki wpływ ma zachowanie pieszych na bezpieczeństwo w ruchu drogowym. W tekście zostały omówione następujące zagadnienia: piesi, jako niechronieni uczestnicy ruchu drogowego; trzy ważne zasady chroniące życie pieszych; zagrożenia dla pieszych i przez pieszych.&#x0D; Metodologia. Główną metodą badawczą wykorzystaną do omówienia zagadnienia bezpieczeństwa pieszych w ruchu drogowym jest analiza źródeł prawnych oraz programów telewizyjnych, artykułów oraz dostępnej literatury naukowej.&#x0D; Wyniki badań. Rozwiązania prawne w zakresie bezpieczeństwa ruchu drogowego obejmujące ochronę pieszych obowiązujące w Polsce należy uznać za wystarczające. Znaczącym problemem jest jednak wciąż nieodpowiednia infrastruktura pieszo-drogowa, która w znaczący sposób mogłaby zmniejszyć ruch pojazdów a uwolnić ruch dla pieszych zwiększając poziom bezpieczeństwa w szczególności w miastach. W konsekwencji zwiększony udział transportu zbiorowego ogranicza ruch innych pojazdów. W artykule wykazano, że lekceważenie przepisów prawa o ruchu drogowym i brak świadomości sytuacyjnej przez pieszych i kierowców pojazdów jest zagadnieniem trudnym do zwalczenia. Bez systemu edukacji i dostosowania treści do poziomu odbiorców nie możemy mówić o długofalowym zapewnieniu bezpieczeństwa pieszym.&#x0D; Wnioski. Bezpieczeństwo ruchu drogowego to nie tylko statystyka i przeciwdziałanie wypadkom. Jest to złożony problem, w którym dziedziny nauki takie jak psychologia, socjologia, biologia, prawo oraz techniczne dyscypliny naukowe powinny ze sobą współpracować. W literaturze naukowej, jaki i opracowaniach instytucjonalnych zajmujących się bezpieczeństwem ruchu drogowego, brakuje zajęcia stanowczego stanowiska przez badaczy oraz praktyków zajmujących się tematyka poprawy bezpieczeństwa w ruchu drogowym.

Investigating an Integrated Sensor Fusion System for Mental Fatigue Assessment for Demanding Maritime Operations.

Human-related issues are currently the most significant factor in maritime causalities, especially in demanding operations that require coordination between two or more vessels and/or other maritime structures. Some of these human-related issues include incorrect, incomplete, or nonexistent following of procedures; lack of situational awareness; and physical or mental fatigue. Among these, mental fatigue is especially dangerous, due to its capacity to reduce reaction time, interfere in the decision-making process, and affect situational awareness. Mental fatigue is also especially hard to identify and quantify. Self-assessment of mental fatigue may not be reliable and few studies have assessed mental fatigue in maritime operations, especially in real time. In this work we propose an integrated sensor fusion system for mental fatigue assessment using physiological sensors and convolutional neural networks. We show, by using a simulated navigation experiment, how data from different sensors can be fused into a robust mental fatigue assessment tool, capable of achieving up to detection accuracy for single-subject classification. Additionally, the use of different sensors seems to favor the representation of the transition between mental fatigue states.

MP40: What are the factors contributing to medico-legal risk of procedural interventions performed by physicians practicing emergency medicine?

Introduction: Physicians who practice emergency medicine (EM) often perform procedural interventions, which can occasionally result in unintended patient harm. Our study's objective was to identify and describe the interventions and contributing factors associated with medico-legal (ML) cases involving emergency physicians performing procedural interventions. Methods: The Canadian Medical Protective Association (CMPA) is a not-for-profit, ML organization which represented over 99,000 physicians at the time of this study. We extracted five years (2014-2018) of CMPA data describing closed ML cases involving procedural interventions (e.g. suturing, reducing a dislocated joint) and excluding interventions related to pharmacotherapy (e.g. injection of local anesthetic), diagnosis (electrocardiograms) and physical assessments (e.g. ear exams), performed by physicians practicing EM. We then applied an internal contributing factor framework to identify themes. We analysed the data using descriptive statistics. Results: We identified 145 cases describing 145 patients who had 205 procedures performed in the course of their EM care. The three most common interventions were orthopedic injury management (47/145, 32.4%), wound management (43/145, 29.7%), and Advanced Cardiac Life Support (24/145, 16.6%). Out of 145 patients, 93.8% (136/145) experienced a patient safety event, and 55.9% (76/136) suffered an avoidable harmful incident. One quarter of patients suffered mild harm (34/76, 25.0%), 18.4% of patients died, 14.5% suffered severe harm, and 13.2% moderate harm. Peer experts were critical of 86/145 cases (59.3%) where the following provider contributing factors were found: a lack of situational awareness (20/68, 29.4%), and deficient physician clinical decision-making (54/68, 79.7%). Clinical decision-making issues included a lack of thoroughness of assessment (33/54, 61.1%), failure to perform tests or interventions (21/54, 38.9%), and a delay or failure to seek help from another physician (17/54, 31.2%). Peer experts were also critical of 48.8% of cases containing team factors (42/86) due to deficient medical record keeping (26/42, 61.9%), and communication breakdown with patients or other team members (25/42, 59.5%). Conclusion: Both provider and team factors contributed to ML cases involving EM physicians performing procedural interventions. Addressing these factors may improve patient safety and reduce ML risk for physicians.