Search results for " Human error"

THERP and HEART integrated methodology for human error assessment

2014

Medical errors are one of the leading causes of death and injury in radiation therapy administration as reported in the literature. This point out an overall deficiency in management allowing patient treatment in the absence of suitable quality assurance processes. Clinical records of major accidental exposure events in radiotherapy show that there is a combination of factors contributing to the accident such as deficient staff training, lack of independent checks, lack of quality control procedures, and absence of overall supervision. Another finding is that training generally addresses only normal situations and does not prepare radiotherapy staff for unusual situations, resulting in a la…

Human error contribution to accidents in the manufacturing sector: A structured approach to evaluate the interdependence among performance shaping fa…

2023

Since the 1970s, Human Reliability Analysis (HRA) methods have received a great interest for the quantification of the Human Error Probability (HEP) in Nuclear Power Plants (NPPs). To this purpose, the second-generation HRA methods consider contextual and cognitive factors - named Performance Shaping Factors (PSFs) - that may influence the workers’ performance during tasks execution. Despite the recent extension of HRA methods to different fields, only few studies refer to the manufacturing sector. In addition, the majority of contributions assume the independence among PSFs, which may result in an over or under estimation of HEP. Therefore, the present paper focuses on the manufacturing se…

THERP and HEART integrated methodology for human error assessment

2015

Abstract THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead to patient radiological overexposures. The results allow for the identification of human errors that are necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so that it can be properly monitored and appropriately managed.

A System Dynamics approach to improve clinical risk management effectiveness in an italian hospital ward: a case study.

Linguistic Approach to Support Human Reliability Analysis and Validation Work in Advanced Radiotherapy Technologies

2019

An integrated methodology, that combines Hierarchical Task Analysis (HTA), Cognitive Task Analysis (CTA) and a modified Human Error Assessment and Reduction Technique (HEART), is proposed to identify safety-relevant human actions in innovative and advanced facilities. It is suggested to use in HEART the concept of linguistic expressions for proportion assessment factors. To prove its applicability, a case study is presented. The validation work has related to safety analyses of accidental events that can involve radiological over-exposure of patients during proton therapy treatments carried out by CATANA (Centro di AdroTerapia Applicazioni Nucleari Avanzate) centre, Italy. CATANA is the fir…

Analisi di sicurezza nella procedura di protonterapia oculare applicata presso i Laboratori del Sud dell’INFN di Catania

2017

A partire dal 2002, l’Azienda Ospedaliera Universitaria “Policlinico Vittorio Emanuele” di Catania ha effettuato il trattamento di circa 350 pazienti affetti da neoplasie oculari mediante fasci di protoni prodotti con il ciclotrone disponibile presso i Laboratori nazionali del Sud (LNS). Tale impianto viene utilizzato per attività di ricerca nell’ambito della fisica sperimentale, per cui è stato necessario modificare le caratteristiche del fascio, rendendolo idoneo alle applicazioni cliniche. Il lavoro di ricerca ha riguardato lo svolgimento della analisi del rischio volto ad individuare possibili fallimenti nelle procedure adottate per il trattamento del paziente sottoposto a cicli di prot…

Fuzzy modelling of HEART methodology: application in safety analyses of accidental exposure in irradiation plants

2009

The present paper refers to the obtained results by using Fuzzy Fault Tree analyses of accidental scenarios which entail the potential exposure of operators working in irradiation industrial plants. For these analyses the HEART methodology, a first generation of the Human Reliability Analysis method, has been employed to evaluate the probability of human erroneous actions. This technique has been modified by us on the basis of fuzzy set concept to more directly take into account the uncertainties of the so called error-promoting factors, on which the method is grounded. The results allow also to provide some recommendations on procedures and safety equipments to reduce the radiological expo…