Wrong-site craniotomy: analysis of 35 cases and systems for prevention

2010 ◽  
Vol 113 (3) ◽  
pp. 461-473 ◽  
Author(s):  
Fred. L. Cohen ◽  
Daniel Mendelsohn ◽  
Mark Bernstein
Keyword(s):  
Human Error ◽  
Case Review ◽  
Contributing Factors ◽  
Public Attention ◽  
Human Errors ◽  
Strict Adherence ◽  
Communication Breakdown ◽  
Surgical Error ◽  
Clinical Consequences ◽  
Wrong Site

Object The purpose of this case review was to identify and analyze existing wrong-site craniotomy (WSC) cases to determine the factors that contributed to the errors and to suggest preventative strategies for WSC. Wrong-site surgery (WSS) is a devastating surgical error that has gained increased public attention in recent years due to some high-profile cases. Despite the implementation of preventative methods such as preoperative checklists and surgical time-outs, WSS still occurs to this day. The clinical consequences of WSC are distinct compared with other types of WSS due to the unique function of the brain. Methods The authors searched medical, legal, and media databases and contacted state medical licensing boards to identify and gather information about WSC cases. The cases were reviewed and analyzed for factors that contributed to the errors. Results Four major categories of contributing factors were found: 1) communication breakdown; 2) inadequate preoperative checks; 3) technical factors and imaging; and 4) human error. The WSC cases are used to illustrate how these types of factors can precipitate the surgical error. Clinical outcomes and disciplinary actions are summarized. Obtaining information about the cases discovered was very challenging, in part because WSS reporting is inadequate. Conclusions This case review demonstrates that a broad range of events and factors can cause human errors to breach patient safeguards and lead to a WSC; however, in essentially all cases the WSCs were preventable with strict adherence to comprehensive and thorough protocols.

scholarly journals How do we prevent and mitigate crashes? Evidence from Australian at-scene in-depth crash investigations

2020 ◽  
Vol 31 (2) ◽  
pp. 35-43 ◽  
Author(s):  
Sam Doecke ◽  
James Thompson ◽  
Christopher Stokes
Keyword(s):  
Human Error ◽  
Stability Control ◽  
Driving Under The Influence ◽  
Contributing Factors ◽  
Human Errors ◽  
Automotive Safety ◽  
The Road ◽  
Emergency Braking ◽  
Safety Research ◽  
Vehicle Technologies

The Centre for Automotive Safety Research conducts at-scene in-depth investigations of South Australian injury crashes that allow detailed analysis of the crash in order to determine the factors that contributed to the crash occurring, and the interventions that could prevent or mitigate them. This initial analysis of such a dataset (n=116) showed that the most common contributing factors are human errors, but the interventions to prevent or mitigate the crashes are most commonly infrastructure treatments or vehicle technologies that eliminate the human error and/or reduce the vehicle’s speed prior to impact in the event of a human error. It also found that most crashes can be prevented or mitigated. Key factors in meeting the goals of the safe system (zero deaths and serious injuries) were found to be: road infrastructure-based interventions at intersections (e.g. roundabouts); increased fleet penetration of the vehicle technologies Electronic Stability Control, Autonomous Emergency Braking, Emergency Braking Assist, Lane Keep Assist, Intelligent Speed Assist – Limiting; road interventions for errant vehicles that depart their lane or the road (e.g. median barriers); speed limit reductions; and a reduction in driving under the influence of alcohol and/or drugs.

Associations between Errors and Contributing Factors in Aircraft Maintenance

2003 ◽  
Vol 45 (2) ◽  
pp. 186-201 ◽  
Author(s):  
Alan Hobbs ◽  
Ann Williamson
Keyword(s):  
Human Error ◽  
Time Pressure ◽  
Aircraft Maintenance ◽  
Contributing Factors ◽  
Pressure Potential ◽  
Organizational Safety ◽  
Human Errors ◽  
Potential Applications ◽  
Error Probabilities ◽  
Maintenance Personnel

In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.

Causes of Structural Failures with Steel Structures

2017 ◽  
Author(s):  
Goran Alpsten
Keyword(s):  
Structural Damage ◽  
Human Error ◽  
Structural Reliability ◽  
Steel Structures ◽  
Fatigue Loading ◽  
Structural Instability ◽  
Human Errors ◽  
Collapse Mode ◽  
Load Carrying ◽  
Structural Failures

This paper is based on the experience from investigating over 400 structural collapses, incidents and serious structural damage cases with steel structures which have occurred over the past four centuries. The cause of the failures is most often a gross human error rather than a combination of “normal” variations in parameters affecting the load-carrying capacity, as considered in normal design procedures and structural reliability analyses. Human errors in execution are more prevalent as cause for the failures than errors in the design process, and the construction phase appears particularly prone to human errors. For normal steel structures with quasi-static (non-fatigue) loading, various structural instability phenomena have been observed to be the main collapse mode. An important observation is that welds are not as critical a cause of structural steel failures for statically loaded steel structures as implicitly understood in current regulations and rules for design and execution criteria.

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

2021 ◽  
Author(s):  
Mohammad S. Alyahya ◽  
Yousef S. Khader ◽  
Nihaya A Al-Sheyab ◽  
Khulood K. Shattnawi ◽  
Omar F. Altal ◽  
...  
Keyword(s):  
Cost Of Care ◽  
Delay Model ◽  
Case Review ◽  
Contributing Factors ◽  
Neonatal Deaths ◽  
Staff Members ◽  
Danger Signs ◽  
Modifiable Factors ◽  
Review Form ◽  
The Cost

Objective This study employed the “three-delay” model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan. Study Design A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected. Results During the study period (August 1, 2019–February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths. Conclusion The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors. Key Points

A Method for Marine Human Error Probability Estimate: APJE-SLIM

2011 ◽  
Vol 97-98 ◽  
pp. 825-830 ◽  
Author(s):  
Yong Tao Xi ◽  
Chong Guo
Keyword(s):  
Collision Avoidance ◽  
Human Error ◽  
Shipping Industry ◽  
Human Reliability ◽  
Combined Method ◽  
Probability Estimate ◽  
Human Errors ◽  
Performance Shaping Factors ◽  
Industry Research ◽  
Human Error Probability

Safety is the eternal theme in shipping industry. Research shows that human error is the main reason of maritime accidents. Therefore, it is very necessary to research marine human errors, to discuss the contexts which caused human errors and how the contexts effect human behavior. Based on the detailed investigation of human errors in collision avoidance behavior which is the most key mission in navigation and the Performance Shaping Factors (PSFs), human reliability of mariners in collision avoidance was analyzed by using the integration of APJE and SLIM. Result shows that this combined method is effective and can be used for the research of maritime human reliability.

Identification of Human Errors During Early Design Stage Functional Failure Analysis

2018 ◽  
Author(s):  
Lukman Irshad ◽  
Salman Ahmed ◽  
Onan Demirel ◽  
Irem Y. Tumer
Keyword(s):  
Failure Analysis ◽  
Human Error ◽  
System Level ◽  
Design Stage ◽  
Human Factors Engineering ◽  
Human Errors ◽  
Functional Failure ◽  
Early Design ◽  
Early Design Stage ◽  
Early Design Stages

Detection of potential failures and human error and their propagation over time at an early design stage will help prevent system failures and adverse accidents. Hence, there is a need for a failure analysis technique that will assess potential functional/component failures, human errors, and how they propagate to affect the system overall. Prior work has introduced FFIP (Functional Failure Identification and Propagation), which considers both human error and mechanical failures and their propagation at a system level at early design stages. However, it fails to consider the specific human actions (expected or unexpected) that contributed towards the human error. In this paper, we propose a method to expand FFIP to include human action/error propagation during failure analysis so a designer can address the human errors using human factors engineering principals at early design stages. To explore the capabilities of the proposed method, it is applied to a hold-up tank example and the results are coupled with Digital Human Modeling to demonstrate how designers can use these tools to make better design decisions before any design commitments are made.

scholarly journals Probabilistic Safety Analysis of High Speed and Conventional Lines Using Bayesian Networks

2016 ◽  
Author(s):  
Zacarias Grande Andrade ◽  
Enrique Castillo Ron ◽  
Alan O'Connor ◽  
Maria Nogal
Keyword(s):  
Bayesian Network ◽  
High Speed ◽  
Human Error ◽  
Driver Behavior ◽  
Safety Evaluation ◽  
Safety Analysis ◽  
Human Errors ◽  
Maintenance Costs ◽  
Railway Line ◽  
Probabilistic Safety

A Bayesian network approach is presented for probabilistic safety analysis (PSA) of railway lines. The idea consists of identifying and reproducing all the elements that the train encounters when circulating along a railway line, such as light and speed limit signals, tunnel or viaduct entries or exits, cuttings and embankments, acoustic sounds received in the cabin, curves, switches, etc. In addition, since the human error is very relevant for safety evaluation, the automatic train protection (ATP) systems and the driver behavior and its time evolution are modelled and taken into account to determine the probabilities of human errors. The nodes of the Bayesian network, their links and the associated probability tables are automatically constructed based on the line data that need to be carefully given. The conditional probability tables are reproduced by closed formulas, which facilitate the modelling and the sensitivity analysis. A sorted list of the most dangerous elements in the line is obtained, which permits making decisions about the line safety and programming maintenance operations in order to optimize them and reduce the maintenance costs substantially. The proposed methodology is illustrated by its application to several cases that include real lines such as the Palencia-Santander and the Dublin-Belfast lines.DOI: http://dx.doi.org/10.4995/CIT2016.2016.3428

scholarly journals OPTIMALISASI PENERIMAAN REMUNERASI DOSEN MENGGUNAKAN METODE RULE BASE REASONING

2019 ◽  
Vol 6 (3) ◽  
pp. 224
Author(s):  
Samsudin Samsudin
Keyword(s):  
Expert System ◽  
Human Error ◽  
Work Performance ◽  
Object Oriented ◽  
Object Oriented Programming ◽  
Rule Base ◽  
Human Knowledge ◽  
Human Errors ◽  
Web Based ◽  
Web Based System

<p><em>Remuneration is a term that relates to employee payroll which is set by certain regulations routinely based on work values, with the aim of creating better and cleaner governance and increasing motivation and work performance. Performance is determined by assessing the compilation oflecturer’swork files and then verified by the department that responsible to it. Rule Base Reasoning is an expert system based on a series of rules that represent human knowledge and experience in solving some complex cases. Expert system is a system whose capability to adopt human knowledge in solving problems so the system can solve problems as is usually done by experts. To implement this method a web-based system is used using the PHP programming language with the concept of Object Oriented Programming with ecpectation this system can be designed more easily and can be developed continuously so it can optimize the acceptance of lecturer remuneration andso far it can minimize the possibility of errors due to human errors. on institutions and lecturers.</em></p><p><strong>Keywords</strong>: <em>Remuneration, Rule Base Reasoning, Performance, Lecturers, Expert Systems.</em><strong><em> </em></strong></p><p><em>Remunerasi merupakan sebuah istilah yang berhubungan dengan penggajian pegawai yang ditetapkan dengan peraturan tertentu secara rutin berdasarkan nilai-nilai kerja, dengan tujuan terciptanya tata kelola yang lebih baik dan bersih serta meningkatkan motivasi dan prestasi kerja.Kinerja ditentukan dengan pengumpulan bukti kerja kepada pihak yang bertanggung jawab dan dihitung oleh badan yang ditentukan.Rule Base Reasoning adalah sistem pakar berdasarkan serangkaian aturan-aturan yang merupakan representasi dari pengetahuan dan pengalaman manusia dalam memecahkan kasus yang rumit</em><em>. </em><em>Sistem pakar adalah suatu sistem yang berusaha mengadopsi pengetahuan manusia dalam menyelesaikan masalah sehingga sistem tersebut dapat menyelesaikan masalah seperti yang biasa dilakukan oleh para pakar</em><em>.</em><em>Untuk mengimplementasikan metode ini dibuat sebuah sistem berbasis web menggunakan bahasa pemrograman PHP dengan konsep Object Oriented Programming dengan harapan sistem ini bisa dirancang lebih mudah dan bisa dikembangkan secara berkelanjutan dan dapat mengoptimalkan penerimaan remunerasi dosen sehingga bisa memperkecil kemungkinan terjadinya kesalahan karena human error yang bisa menyebabkan kerugian pada pihak institusi maupun dosen.</em></p><p><strong>Kata kunci</strong>: <em>Remunerasi, Rule Base Reasoning, Kinerja, Dosen, Sistem Pakar.</em><strong></strong></p>

scholarly journals Implementation of Heart and Dematel Integration to Steam Boiler Working Process

2021 ◽  
Vol 5 (2) ◽  
pp. 1-17
Author(s):  
Gülin Feryal Can
Keyword(s):  
Error Probability ◽  
Human Error ◽  
Reduction Technique ◽  
Steam Boiler ◽  
Error Assessment ◽  
Working Process ◽  
Human Errors ◽  
Process Error ◽  
Powerful Approach ◽  
Advanced Version

Human Error Assessment and Reduction Technique (HEART) is a practical and powerful approach to prioritize errors related to human actions, based on probabilities. HEART can determine error producing conditions (EPCs) which cause human errors for different processes including main duties (MDs) and sub-duties (SDs). HEART can be applied quickly for any process where human reliability is important. In this study, HEART and advanced version of Decision Making Trial and Evaluation Laboratory (AV-DEMATEL) integration proposed by Can and Delice in 2018 was performed for evaluating human related errors in steam boiler working process. In this way, the interactions between MDs, SDs and EPCs in a steam boiler working process were considered to compute process error probability (PEP). Additionally, the applicability of the proposed approach by Can and Delice (2018) was demonstrated again.

Impact of Human Factors on Measurement Errors

2013 ◽  
pp. 274-291 ◽  
Author(s):  
Vinodkumar Jacob ◽  
M. Bhasi ◽  
R. Gopikakumari
Keyword(s):  
Experimental Study ◽  
Statistical Analysis ◽  
Measurement Error ◽  
Measurement Errors ◽  
Human Error ◽  
Quantitative Comparison ◽  
Measuring System ◽  
Measuring Instrument ◽  
Related Factors ◽  
Human Errors

Measurement is the act or the result, of a quantitative comparison between a given quantity and a quantity of the same kind chosen as a unit. It is for observing and testing scientific and technological investigations and generally agreed that all measurements contain errors. In a measuring system where both a measuring instrument and a human being taking the measurement using a preset process, the measurement error could be due to the instrument, the process or human error. This study is devoted to understanding the human errors in measurement. Work and human involvement related factors that could affect measurement errors have been identified. An experimental study has been conducted using different subjects where the factors were changed one at a time and the measurements made by them recorded. Errors in measurement were then calculated and the data so obtained was subject to statistical analysis to draw conclusions regarding the influence of different factors on human errors in measurement. The findings are presented in the paper.

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