Search results for "Human error"
showing 10 items of 20 documents
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…
Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study.
2021
BackgroundFor over a decade, the preoperative timeout procedure has been implemented in most paediatric surgery units. However, the impact of this intervention has not been systematically studied. This study evaluates whether purposefully introduced errors during the timeout routine are detected and reported by the operating team members.MethodsAfter ethics board approval and informed consent, deliberate errors were randomly and clandestinely introduced into the timeout routine for elective surgical procedures by a paediatric surgery attending. Errors were randomly selected among wrong name, site, side, allergy, intervention, birthdate and gender items. The main outcome measure was how freq…
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…
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.
Risk analysis using fuzzy set theory of accidental exposure of medical staff during brachytherapy procedures
2010
Using fuzzy set theory, this paper presents results from risk analyses that explore potential exposure of medical operators working in a high dose rate brachytherapy irradiation plant. In these analyses, the HEART methodology, a first generation method for human reliability analysis, has been employed to evaluate the probability of human error. This technique has been modified on the basis of fuzzy set concepts to take into account, more directly, the uncertainties of the so-called error-promoting factors on which the method is based. Moreover, with regard to some identified accident scenarios, fuzzy potential dose was also evaluated to estimate the relevant risk. The results also provide s…
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…
An Aircraft Pilot Workload Sensing System
2021
The workload evaluation is of great importance for human error avoidance training, particularly in the use of complex systems that requires different and concurrent activities. The excessive workload harms human performance even with adverse outcomes. In the aviation field, certain flight maneuvers, such as take-off and landing, are characterized by great attention and workload demand to the pilot. Thus, a system capable of measuring pilots’ workload levels during flight could be beneficial to increase pilots’ performance. This work aims to study the initial feasibility of a device called Cockpit Pilot Warning System that monitors the pilot workload level during flight. With this aim, an ex…
Modelling safety climate in the prediction of levels of safety activity
1998
Abstract This study examined the architecture of the relationships between components of organizational safety climate, including employee attitudes to safety issues and perceptions of the work environment, and related this to self-reported levels of safety activity. Data were collected from a large multinational manufacturing organization by questionnaire. A total of 915 valid questionnaires were returned and formed the basis for structural equation modelling and subsequent analyses. These data showed that a common structure, or architecture, of attitudes to safety issues and perceptions of the work environment could be constructed that explained levels of safety activity. The strength of …
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…