Human Error Theory Research Articles

The Impact of Ancient Book Image Quality on Cultural Heritage Crowdsourcing Correction Tasks: A Human Error Theory Perspective

ABSTRACTThis study investigates the impact of ancient book image quality on the accuracy of cultural heritage crowdsourcing correction tasks. The study processed 27 pictures from an ancient book to adjust their quality in terms of clarity, seal coverage and background color. Based on human error theory, the study divided common errors made by participants in correction tasks into slips and mistakes, and analyzed the impact of different image qualities on these errors. The experiment was conducted using an online experiment platform, with 25 participants each completing 6 tasks related to clarity, seal coverage, and background color. The results show that the clarity of ancient book images significantly affects the number of rectifications and mistakes in the tasks. Different degrees of seal coverage significantly impact the number of rectifications and slips, while the background color of the images mainly affects the number of mistakes.

Educational preparedness and perceived importance on confidence in new graduate registered nurses' medication administration

BackgroundMedication errors are the most common type of error affecting patient safety and the most preventable cause of adverse medical events globally. Medication errors occur most frequently (33.3 %) during the administration phase. New nurses felt their education left them vulnerable to errors, suggesting that current curricula may be insufficient. PurposeThe purpose of this study was to determine the relationship between new nurses' educational preparedness and perceived importance with confidence in medication administration. A secondary aim was to determine the difference in the variables based on demographic information. MethodsA descriptive, correlational design was employed using the Theory of Human Error. Ohio newly licensed nurses were surveyed for their educational preparedness, perceived importance, and confidence in nine medication competencies. Descriptive and inferential statistics were used. ResultsN = 201. A significant, positive relationship was found between both educational preparedness and confidence, and perceived importance and confidence. Nurses reported high levels of educational preparedness, perceived importance, and confidence. All correlations and regressions were significant, indicating that as nurse educational preparedness and/or perceived importance increases, the odds of confidence increases. Demographic analysis demonstrated that practice area and years of experience significantly contributed to differences in the variables. ConclusionsUnderstanding the educational preparedness and perceived importance of the medication competencies can help guide future research into creating educational and clinical interventions to ultimately decrease medication errors.

Technology alone does not achieve error reduction - a study of handwritten, tick-sheet, ink stamp and electronic medical prescriptions

Technology in the form of electronic record systems and prescriptions have been touted as a potential solution to human error. In South Africa, a middle-income country where health facilities have large variations in technological capacity, prescription errors can be complex and varied. We evaluated different prescribing methods to find if the increased use of technology in prescriptions will assist in reducing error rates. A retrospective, non-randomised study compared prescriptions, error rates and types in four hospitals with different prescribing methods: these were handwritten, ink stamp, tick-sheet and electronic prescriptions. A modern human error theory data collection tool was designed which included patient complexity. Cataract surgery was chosen as the single common procedure. One thousand six hundred and sixty-one individual scripts had 1 307 prescription errors. Increasing patient complexity was not an indicator of error rate. Handwritten and tick-sheet prescriptions had the fewest errors (49% and 51%, respectively). Electronic (96%) and ink stamp scripts (101%) had almost twice as many errors as handwritten scripts (p < 0.001) mainly due to systemic inbuilt errors. The application of increasing degrees of technological complexity does not automatically reduce error rate. This is especially apparent when technology is not integrated into human factors engineering and persistent critical assessment.

Weapon Confusion: TASER CEWs, Firearms, and Human Error Theories

Norman's human action theory and Reason's human error theory provide frameworks to analyze and to understand weapon confusion wherein a police officer mistakenly draws and discharges a firearm rather than a stated intent of deploying a TASER CEW. Review of publicly available information culminated in qualitative analysis of 20 TASER CEW/firearm confusion shootings that revealed evidence of capture error and action execution slips. Although changes in policy and training have not eliminated such errors, there is evidence they might have had some success in reducing the frequency. Systematic and simultaneous changes in weapon design, policies, training, and procedures might be necessary to reduce or eliminate weapon confusion but must be carefully assessed to avoid negative unintended consequences.

How Software Developers Mitigate Their Errors When Developing Code

Code remains largely hand-made by humans and, as such, writing code is prone to error. Many previous studies have focused on the technical reasons for these errors and provided developers with increasingly sophisticated tools. Few studies have looked in detail at why code errors have been made from a human perspective. We use Human Error Theory to frame our exploratory study and use semi-structured interviews to uncover a preliminary understanding of the errors developers make while coding. We look particularly at the Skill-based (SB) errors reported by 27 professional software developers. We found that the complexity of the development environment is one of the most frequently reported reasons for errors. Maintaining concentration and focus on a particular task also underpins many developer errors. We found that developers struggle with effective mitigation strategies for their errors, reporting strategies largely based on improving their own willpower to concentrate better on coding tasks. We discuss how using Reason’s Swiss Cheese model may help reduce errors during software development. This model ensures that layers of tool, process and management mitigation are in place to prevent developer errors from causing system failures.

Eventos adversos em uma unidade de internação psiquiátrica

ABSTRACT Objective to describe the adverse events found in psychiatric hospitalization, analyzing them in the light of the human error theory. Method a qualitative research study, carried out in 2018 in a psychiatric hospital. The data were collected through semi-structured interviews with 15 health professionals from the multidisciplinary team. Analysis was of the lexical type using the Alceste software. Results adverse drug events were evidenced due to administration errors or adverse drug reactions, which produce harms such as impregnation and extrapyramidal reactions associated with the risks for falls and bronchoaspiration due to drowsiness and/or sedation. Other harms are related to the patient's aggressiveness, which produce bodily self-harm or harms to another person, such as during a suicide attempt or use of violence as an escape or defense behavior. Conclusion and implications for the practice some adverse events are more frequent in psychiatric hospitalization settings; such events need to be known by the mental health team, as they require mitigation actions through the strengthening of patient safety systems. The data subsidize actions for strengthening safety systems in psychiatric hospitalization settings and contribute to reflecting on the concept of patient safety in Psychiatry.

Survey of Nursing Faculty Preparation for Guiding DNP Quality Improvement Projects.

Quality improvement (QI) projects comprise the majority of University of Maryland School of Nursing (UMSON) Doctor of Nursing Practice (DNP) projects. An online survey was completed by 51% (n = 38) of faculty, who teach or mentor DNP students, and was analyzed using quantitative and descriptive methods. Faculty were somewhat or not familiar with developing a QI charter 68.4%, human error theory and error proofing 63.2%, driver diagrams 60.5%, characteristics of high-reliability organizations 60.5%, and Standards for Quality Improvement Reporting Excellence (SQUIRE) guidelines 55.3%. The faculty were most interested in learning more about (n = 97 responses) were human error theory and error proofing (28.9%), SQUIRE guidelines (26.3%), statistical process control (21.1%), and implementation strategies and tactics (21.1%). The most commonly identified challenges included identifying QI projects (24%), project time constraints (16%), keeping up-to-date on QI concepts, methods, and tools (12%), and balancing professional workload (10%). Gaps in self-reported QI knowledge indicate there is a need for further development of DNP and PhD prepared faculty at the UMSON.

INTRAVENOUS MEDICATION ADMINISTRATION ERRORS AND THIS CAN ENDANGER THE LIVES OF PATIENTS

Objective: Intravenous errors are one of the most frequent and common medical errors, but no direct causes found. The theory of human error is the most common expression of errors in hospitals, and this can endanger the lives of patients. This research study aims to identify the errors in the vein and try to find solutions to avoid those errors where the study conducted on a sample of hospitals in Baghdad.&#x0D; Methods: The study conducted to improve health quality in some hospitals. During the study period, a group of severe cases was detected, which based on intravenous infusions. Patients’ data and information were collected through five sources, examined and documented venous errors found and placed in a standard classification according to an incorrect dose and incorrect medication. The incorrect dose includes the following: Overdose, extra dose, underdose, wrong strength, and wrong form.&#x0D; Results: During the period of study, a total of 99 cases, among these cases, 52 incorrect medications include (drug-drug interaction, drug-disease interaction, and not indicated medication) the incorrect dose 42 and route of administration and incorrect rate also take place in mistakes.&#x0D; Conclusion: Intravenous errors can cause significant harm to patients and health-care providers, so proper attention paid to them. Several reasons may cause medication errors such as lack of experience and knowledge of health-care providers, inaccurate communications that do not explain the drug, and the exact dose. The prescribing errors in the medication or dosage were collected, discussed, and clarified so that the risks arising from them observed so that health-care providers and hospital specialists would be alerted and the study would serve as an alarm for health organizations.

FMARI Application in Innovation and IT for Accidents' Investigation

FMARI Database Application is designed to help safety auditor in investigating work accidents and as routine monitoring in regular companies reports to safety board organization in Indonesia (BPJS for Employee) with the main goal is to reach zero accident. FMARI stands for Faktor Manusia dan Analisis Resiko Industri (application: Human Factors and Industrial Risk Analysis) is following HFACS method and make a modification from HFIX in Indonesian terms. The Human Factors Analysis and Classification System (HFACS) is a system-safety model that effectively bridges the gap between human error theory and applied human error analysis. The Human Factors Intervention matriX (HFIX) is an innovative tool for mapping intervention strategies onto the specific forms of human error identified in the HFACS.

Error-producing conditions in nursing staff work.

To analyze the errors made by nursing staff workers who faced ethical-disciplinary actions. Document, exploratory, quanti-qualitative research. The information was collected in 13 ethical-disciplinary actions of COREN BA, dated from 1995 to 2010, which had as object of complaint an error made by nursing staff workers. The quantitative data were analyzed using descriptive statistics and the qualitative data was analyzed using the Human Error Theory and Sociology of Work. Nursing technicians and assistants held most actions. The health institution, through the nursing service coordination, was the predominant complainer and the most frequent shift was daytime. The errors made by nursing staff workers demonstrate that error-producing conditions are present in the context of their occurrence in all actions, and understaffing and intensity of work are the most recurrent circumstances.

An evaluation of a flipped approach to risk training in the operating theatre.

Operating departments are high-risk environments in which a safety culture is fundamental to managing inherent risks. Management of risk is an integral part of the local preceptorship course for newly qualified staff. The author has provided training for the preceptorship course in an innovative way to enhance and contextualise learning within the safe environment of a classroom. The training provides information about human error theory and how this interacts with the contextual environment of the operating department, producing risky situations.

Reliability Evaluation and Improvement Approach of Chemical Production Man - Machine - Environment System

In recent years, with the gradual extension of reliability research, the study of production system reliability has become the hot topic in various industries. Man-machine-environment system is a complex system composed of human factors, machinery equipment and environment. The reliability of individual factor must be analyzed in order to gradually transit to the research of three-factor reliability. Meanwhile, the dynamic relationship among man-machine-environment should be considered to establish an effective blurry evaluation mechanism to truly and effectively analyze the reliability of such systems. In this paper, based on the system engineering, fuzzy theory, reliability theory, human error, environmental impact and machinery equipment failure theory, the reliabilities of human factor, machinery equipment and environment of some chemical production system were studied by the method of fuzzy evaluation. At last, the reliability of man-machine-environment system was calculated to obtain the weighted result, which indicated that the reliability value of this chemical production system was 86.29. Through the given evaluation domain it can be seen that the reliability of man-machine-environment integrated system is in a good status, and the effective measures for further improvement were proposed according to the fuzzy calculation results.

Design Defects and Quality of Government Funded Building Projects In Isiolo County, Kenya

The Interface between design and pre-construction of government funded buildings projects is pivotal and yet very complicated. It is at this interface that defects emanating from design errors in the buildings have been found to occur adversely influencing the realization of quality buildings. This study investigated the influence of design defects on the quality of government funded building projects in Isiolo County. The study is guided by one theory; The Bad Apple Theory of human error. Descriptive survey research design is adopted. Study’s target population consisted; 137project clients, 92 contractors and 16 consultants. 149 respondents made up the study’s sample size and final subjects selected using Stratified and Simple random sampling techniques. Primary data was collected using three questionnaires. The analysis of quantitative data was achieved making use of descriptive statistics and qualitative data on the other hand was reported in form of narratives pivoted on themes under study. The study established that poor functionality of building parts, buildings’ fragility, high occurrence of unpleasant aesthetics in buildings and cost overruns were all as a result of design defects. This study concluded that design defects to a great extent influenced the quality of government funded building projects in Isiolo County. The study recommends that a design review involving project clients and consultants prior to the approval of the final design for construction should beunder taken. Further, to address design defects architectures should provide clear graphic and written representations which will allow contractors to transform concepts into physical reality in execution of government funded building projects in Is iolo County.

‘Little wake turbulence, huh?’ Applying a contemporary model of learning and memory to the American Airlines Flight AA587 accident

ABSTRACTLoss of control has become a leading cause of aviation accidents and human error is often recorded as the cause in favour of other factors. This has the effect of downgrading the significance of corrective actions to address deeper systemic issues, and serves the bad-apple theory of human error. This paper uses a model of learning and memory to expand on the analysis of negative training from the AA587 accident, which documented the actions of the First Officer as the probable cause and training as contributory. Evidence from the investigation and our contemporary understanding of learning and memory is used to explain how the experiences of the First Officer fit the scenario in which the accident occurred, such that it is plausible to extend probable cause beyond his actions. The paper develops a model of causal inference that enables analysts to continue probing causality as part of a systems approach.

Applied Human Error Theory

Since 2001, there have been 10 documented instances of TASER/handgun weapon-confusion shootings by police. In each of these cases, the TASERs were carried in a configuration that facilitated being drawn with the dominant (strong) hand. One police human factors expert has attributed the unintentional shootings to slip errors and capture errors. While some laypersons have disputed this – usually without any proof of alternative theories – very little literature analyzing these shootings in light of prevalent human error theory exists. This paper applies current slip-and-capture theory to the facts of a highly publicized and well-documented case, concluding that this police TASER-confusion shooting falls within those theoretical frameworks. The need for further research and the criminalization of such errors is briefly discussed.

Slips, lapses and mistakes inthe use of equipment by nurses in an intensive care unit.

Toidentify the occurrence of errors in the use of equipment by nurses working in intensive careandanalyzing them in the framework of James Reason's theory of human error. Qualitative field study in the intensive care unit of a federal hospital in the city of Rio de Janeiro. Observation and interviews were conductedwith eight nurses, from March to December 2014. Content analysis was used for the interviews, as well as the description of the scenes observed. Lapses of memory and attention were identified in the handling of infusion pumps, as well as planning failures during the programming of monitors. Errors cause adverse events that compromise patient safety. The authors propose creation of an instrument for daily checking of equipment, with checks throughout the work process in the programming of infusion pumps and monitors, in order to reduce failures and memory lapses. Identificar a ocorrência de erros na utilização de equipamentos por enfermeiros que atuam na terapia intensiva, analisando-os à luz da teoria do erro humano de James Reason. Pesquisa de campo, qualitativa, na Unidade de Terapia Intensiva de um hospital federal do Rio de Janeiro. Realizou-se observação e entrevista com oito enfermeiros, de março a dezembro de 2014. Aplicou-se análise de conteúdo nas entrevistas e descrição densa nas cenas observadas. Identificaram-se falhas de memória e de atenção no manuseio das bombas infusoras e falhas de planejamento durante a programação dos monitores. Os erros causam eventos adversos que comprometem a segurança do paciente. Propõe-se um instrumento de verificação diária dos equipamentos, com checagens ao longo do processo de trabalho da programação das bombas infusoras e monitores, no intuito de reduzir as falhas e esquecimentos.

Human error in daily intensive nursing care.

Objectives: to identify the errors in daily intensive nursing care and analyze them according to the theory of human error. Method: quantitative, descriptive and exploratory study, undertaken at the Intensive Care Center of a hospital in the Brazilian Sentinel Hospital Network. The participants were 36 professionals from the nursing team. The data were collected through semistructured interviews, observation and lexical analysis in the software ALCESTE(r). Results: human error in nursing care can be related to the approach of the system, through active faults and latent conditions. The active faults are represented by the errors in medication administration and not raising the bedside rails. The latent conditions can be related to the communication difficulties in the multiprofessional team, lack of standards and institutional routines and absence of material resources. Conclusion: the errors identified interfere in nursing care and the clients' recovery and can cause damage. Nevertheless, they are treated as common events inherent in daily practice. The need to acknowledge these events is emphasized, stimulating the safety culture at the institution.

Understanding safety in healthcare: the system evolution, erosion and enhancement model.

The paper summarises previous theories of accident causation, human error, foresight, resilience and system migration. Five lessons from these theories are used as the foundation for a new model which describes how patient safety emerges in complex systems like healthcare: the System Evolution Erosion and Enhancement model. It is concluded that to improve patient safety, healthcare organisations need to understand how system evolution both enhances and erodes patient safety.Significance for public healthThe article identifies lessons from previous theories of human error and accident causation, foresight, resilience engineering and system migration and introduces a new framework for understanding patient safety in healthcare; the System Evolution, Erosion and Enhancement (SEEE) model. The article is significant for public health because healthcare organizations around the world need to understand how safety evolves and erodes to develop and implement interventions to reduce patient harm.

Junior doctors' perceptions of their self‐efficacy in prescribing, their prescribing errors and the possible causes of errors

The aim of the study was to explore and compare junior doctors' perceptions of their self-efficacy in prescribing, their prescribing errors and the possible causes of those errors. A cross-sectional questionnaire study was distributed to foundation doctors throughout Scotland, based on Bandura's Social Cognitive Theory and Human Error Theory (HET). Five hundred and forty-eight questionnaires were completed (35.0% of the national cohort). F1s estimated a higher daytime error rate [median 6.7 (IQR 2-12.4)] than F2s [4.0 IQR (0-10) (P = 0.002)], calculated based on the total number of medicines prescribed. The majority of self-reported errors (250, 49.2%) resulted from unintentional actions. Interruptions and pressure from other staff were commonly cited causes of errors. F1s were more likely to report insufficient prescribing skills as a potential cause of error than F2s (P = 0.002). The prescribers did not believe that the outcomes of their errors were serious. F2s reported higher self-efficacy scores than F1s in most aspects of prescribing (P < 0.001). Foundation doctors were aware of their prescribing errors, yet were confident in their prescribing skills and apparently complacent about the potential consequences of prescribing errors. Error causation is multi-factorial often due to environmental factors, but with lack of knowledge also contributing. Therefore interventions are needed at all levels, including environmental changes, improving knowledge, providing feedback and changing attitudes towards the role of prescribing as a major influence on patient outcome.

Application of human error theories for the process improvement of Requirements Engineering

Problems with the structuring and execution of the Requirements Engineering (RE) process can lead to project failure. As the involved activities are essentially human and subjective, the importance of the human factor must be considered. The possible correlation between human errors and the problems that may occur in the RE process is explored in this paper in order to propose a process improvement approach, which applies the theories of human error to build an expert system for automated diagnosis of problems. This approach starts by assessing the importance of individual types of human errors in different contexts using questionnaires to extract knowledge from RE practitioners. A method for managing the priorities of solutions to improve a given process is then proposed and a prototype application is implemented for evaluation with practitioners. The activities with RE practitioners also provide data that are used to construct and evaluate estimators of the presence of human errors and the affected phases of the RE process. Most of the volunteering participants agree that knowledge of error typologies may help to improve their processes to avoid problems.