Author: David D. Woods
Publisher: CRC Press
Release Date: 2017-09-18
Genre: Technology & Engineering
Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.
WHAT COMMON FACTORS CONNECT THE DEATH OF MARY SANDERS DURING A SIMPLE SURGICAL INTERVENTION, CHERNOBYL NUCLEAR DISASTER, AND THE COSTA CONCORDIA SHIPWRECK? WAS IT A FATAL MINDSET, DEFECTIVE EQUIPMENT, AN ACT OF DESTINY OR...? IT IS THE HUMAN ERROR THE THREAD THAT BINDS THESE (AND MANY OTHER) TRAGIC EVENTS. HOW TO BEST PREVENT, MANAGE AND MITIGATE ITS EFFECTS AND CONSEQUENCES IS THE SUBJECT OF STUDY BY CPT. FERDINANDO RESTINA.
WHAT COMMON FACTORS CONNECT THE DEATH OF MARY SANDERS DURING A SIMPLE SURGICAL INTERVENTION, CHERNOBYL NUCLEAR DISASTER, AND THE COSTA CONCORDIA SHIPWRECK? WAS IT A FATAL MINDSET, DEFECTIVE EQUIPMENT, AN ACT OF DESTINY OR...? IT IS THE HUMAN ERROR THE THREAD THAT BINDS THESE (AND MANY OTHER) TRAGIC EVENTS. HOW TO BEST PREVENT, MANAGE AND MITIGATE ITS EFFECTS AND CONSEQUENCES IS THE SUBJECT OF STUDY BY Captain FERDINANDO RESTINA.
This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.
Author: Robert L. Wears
Publisher: Ashgate Publishing, Ltd.
Release Date: 2015-03-28
Genre: Political Science
Health systems everywhere are expected to meet increasing public and political demands for accessible, high-quality care. Policy-makers, managers, and clinicians use their best efforts to improve efficiency, safety, quality, and economic viability. One solution has been to mimic approaches that have been shown to work in other domains, such as quality management, lean production, and high reliability. In the enthusiasm for such solutions, scant attention has been paid to the fact that health care as a multifaceted system differs significantly from most traditional industries. Solutions based on linear thinking in engineered systems do not work well in complicated, multi-stakeholder non-engineered systems, of which health care is a leading example. A prerequisite for improving health care and making it more resilient is that the nature of everyday clinical work be well understood. Yet the focus of the majority of policy or management solutions, as well as that of accreditation and regulation, is work as it ought to be (also known as ‘work-as-imagined’). The aim of policy-makers and managers, whether the priority is safety, quality, or efficiency, is therefore to make everyday clinical work - or work-as-done - comply with work-as-imagined. This fails to recognise that this normative conception of work is often oversimplified, incomplete, and outdated. There is therefore an urgent need to better understand everyday clinical work as it is done. Despite the common focus on deviations and failures, it is undeniable that clinical work goes right far more often than it goes wrong, and that we only can make it better if we understand how this happens. This second volume of Resilient Health Care continues the line of thinking of the first book, but takes it further through a range of chapters from leading international thinkers on resilience and health care. Where the first book provided the rationale and basic concepts of RHC, the Resilience of Everyday Clinical Work breaks new ground by analysing everyday work situations in primary, secondary, and tertiary care to identify and describe the fundamental strategies that clinicians everywhere have developed and use with a fluency that belies the demands to be resolved and the dilemmas to be balanced. Because everyday clinical work is at the heart of resilience, it is essential to appreciate how it functions, and to understand its characteristics.
Publisher: Joint Commission on
Release Date: 2005-01-01
Human factors engineering (HFE) is concerned with understanding human characteristics and how humans interact with the world around them, and applying that knowledge to the design of systems that are safe, efficient and comfortable. This book describes how to use HFE tools and principles to curb preventable errors and minimize patient harm.
Author: Keith Reddin
Publisher: Dramatists Play Service Inc
Release Date: 2008
THE STORY: At a crash site somewhere in the Midwest, investigators Miranda and Erik stand amongst the wreckage. Middle-aged colleagues relatively new to each other, they tentatively begin a relationship. Although Miranda initially rebuffs Erik, it
Ten Questions About Human Error asks the type of questions frequently posed in incident and accident investigations, people's own practice, managerial and organizational settings, policymaking, classrooms, Crew Resource Management Training, and error research. It is one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points of views of human factors and system safety. The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.
Computer Control and Human Error presents accounts of various incidents at computer-controlled plants. These incidents include equipment and software faults; treating the computer as a "black box"; misjudging the way operators respond to the computer; errors in the data entry; failure to inform operators of changes in data or programs; and unauthorized interference with peripheral equipment. The discussion then turns to the use of hazard and operability studies (Hazops) to prevent or reduce errors in computer-controlled plants. The book describes the conventional Hazop as used in the process industry and an overview of the different Chazop frameworks/guidelines suggested by engineers and researchers. It then presents new Chazop methodology which is based on incident analysis. The final chapter presents reasons for failures in computerized systems, each of which is illustrated with an example. Most of the examples did not cause an actual safety problem, simply because they occurred within systems that are not safety-related. Some of these examples appear in the literature; others are from personal experience or from private communications.
Author: Professor Scott A Shappell
Publisher: Ashgate Publishing, Ltd.
Release Date: 2012-10-01
This comprehensive book provides the knowledge and tools required to conduct a human error analysis of accidents. Serving as an excellent reference guide for many safety professionals and investigators already in the field.
The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety. The second edition takes a more practical approach with coverage of methods, interventions, and applications and a greater range of domains such as medication safety, surgery, anesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.
Occupational Ergonomics: Principles of Work Design focuses on the fundamentals in ergonomics design and evaluation. Divided into two parts, Part I covers the background for the discipline and profession of ergonomics and offers an international perspective on ergonomics. Part II describes the foundations of ergonomics knowledge, including fundament
The International Encyclopedia of Ergonomics and Human Factors is a truly comprehensive reference guide to the professional world of ergonomics. Reflecting the copious amount of new information provided, the Handbook has been divided into three volumes.The text presents a unified source of reliable, accessible information from the many realms of science and technology contributing to our knowledge of design for human use. It includes human characteristics, performance-related factors, display and control design, work design and organization, health and safety, social and economic issues, and a large reference of methods and techniques. This set includes the full encyclopedia both in print and on CD-ROM.
Author: David M. Gaba
Publisher: Elsevier Health Sciences
Release Date: 2014-08-21
The fully updated Crisis Management in Anesthesiology continues to provide updated insights on the latest theories, principles, and practices in anesthesiology. From anesthesiologists and nurse anesthetists to emergency physicians and residents, this medical reference book will effectively prepare you to handle any critical incident during anesthesia. Identify and respond to a broad range of life-threatening situations with the updated Catalog of Critical Incidents, which outlines what may happen during surgery and details the steps necessary to respond to and resolve the crisis. React quickly to a range of potential threats with an added emphasis on simulation of managing critical incidents. Useful review for all anesthesia professionals of the core knowledge of diagnosis and management of many critical events. Explore new topics in the ever-expanding anesthesia practice environment with a detailed chapter on debriefing. Consult this title on your favorite e-reader, conduct rapid searches, and adjust font sizes for optimal readability.