Human Reliability and the Cost of Doing Business

NASA Technical Reports Server (NTRS)

DeMott, Diana

2014-01-01

Most businesses recognize that people will make mistakes and assume errors are just part of the cost of doing business, but does it need to be? Companies with high risk, or major consequences, should consider the effect of human error. In a variety of industries, Human Errors have caused costly failures and workplace injuries. These have included: airline mishaps, medical malpractice, administration of medication and major oil spills have all been blamed on human error. A technique to mitigate or even eliminate some of these costly human errors is the use of Human Reliability Analysis (HRA). Various methodologies are available to perform Human Reliability Assessments that range from identifying the most likely areas for concern to detailed assessments with human error failure probabilities calculated. Which methodology to use would be based on a variety of factors that would include: 1) how people react and act in different industries, and differing expectations based on industries standards, 2) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 3) type and availability of data and 4) how the industry views risk & reliability influences ( types of emergencies, contingencies and routine tasks versus cost based concerns). The Human Reliability Assessments should be the first step to reduce, mitigate or eliminate the costly mistakes or catastrophic failures. Using Human Reliability techniques to identify and classify human error risks allows a company more opportunities to mitigate or eliminate these risks and prevent costly failures.

Human Reliability and the Cost of Doing Business

NASA Technical Reports Server (NTRS)

DeMott, D. L.

2014-01-01

Human error cannot be defined unambiguously in advance of it happening, it often becomes an error after the fact. The same action can result in a tragic accident for one situation or a heroic action given a more favorable outcome. People often forget that we employ humans in business and industry for the flexibility and capability to change when needed. In complex systems, operations are driven by their specifications of the system and the system structure. People provide the flexibility to make it work. Human error has been reported as being responsible for 60%-80% of failures, accidents and incidents in high-risk industries. We don't have to accept that all human errors are inevitable. Through the use of some basic techniques, many potential human error events can be addressed. There are actions that can be taken to reduce the risk of human error.

Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant

PubMed Central

Jahangiri, Mehdi; Hoboubi, Naser; Rostamabadi, Akbar; Keshavarzi, Sareh; Hosseini, Ali Akbar

2015-01-01

Background A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident. Methods This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability. Results The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%). Conclusion The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided. PMID:27014485

Managing human fallibility in critical aerospace situations

NASA Astrophysics Data System (ADS)

Tew, Larry

2014-11-01

Human fallibility is pervasive in the aerospace industry with over 50% of errors attributed to human error. Consider the benefits to any organization if those errors were significantly reduced. Aerospace manufacturing involves high value, high profile systems with significant complexity and often repetitive build, assembly, and test operations. In spite of extensive analysis, planning, training, and detailed procedures, human factors can cause unexpected errors. Handling such errors involves extensive cause and corrective action analysis and invariably schedule slips and cost growth. We will discuss success stories, including those associated with electro-optical systems, where very significant reductions in human fallibility errors were achieved after receiving adapted and specialized training. In the eyes of company and customer leadership, the steps used to achieve these results lead to in a major culture change in both the workforce and the supporting management organization. This approach has proven effective in other industries like medicine, firefighting, law enforcement, and aviation. The roadmap to success and the steps to minimize human error are known. They can be used by any organization willing to accept human fallibility and take a proactive approach to incorporate the steps needed to manage and minimize error.

Prediction of human errors by maladaptive changes in event-related brain networks.

PubMed

Eichele, Tom; Debener, Stefan; Calhoun, Vince D; Specht, Karsten; Engel, Andreas K; Hugdahl, Kenneth; von Cramon, D Yves; Ullsperger, Markus

2008-04-22

Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve approximately 30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations.

Prediction of human errors by maladaptive changes in event-related brain networks

PubMed Central

Eichele, Tom; Debener, Stefan; Calhoun, Vince D.; Specht, Karsten; Engel, Andreas K.; Hugdahl, Kenneth; von Cramon, D. Yves; Ullsperger, Markus

2008-01-01

Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional MRI and applying independent component analysis followed by deconvolution of hemodynamic responses, we studied error preceding brain activity on a trial-by-trial basis. We found a set of brain regions in which the temporal evolution of activation predicted performance errors. These maladaptive brain activity changes started to evolve ≈30 sec before the error. In particular, a coincident decrease of deactivation in default mode regions of the brain, together with a decline of activation in regions associated with maintaining task effort, raised the probability of future errors. Our findings provide insights into the brain network dynamics preceding human performance errors and suggest that monitoring of the identified precursor states may help in avoiding human errors in critical real-world situations. PMID:18427123

Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

NASA Technical Reports Server (NTRS)

Wiegmann, Douglas A.; Rantanen, Eas M.

2003-01-01

The modus operandi in addressing human error in aviation systems is predominantly that of technological interventions or fixes. Such interventions exhibit considerable variability both in terms of sophistication and application. Some technological interventions address human error directly while others do so only indirectly. Some attempt to eliminate the occurrence of errors altogether whereas others look to reduce the negative consequences of these errors. In any case, technological interventions add to the complexity of the systems and may interact with other system components in unforeseeable ways and often create opportunities for novel human errors. Consequently, there is a need to develop standards for evaluating the potential safety benefit of each of these intervention products so that resources can be effectively invested to produce the biggest benefit to flight safety as well as to mitigate any adverse ramifications. The purpose of this project was to help define the relationship between human error and technological interventions, with the ultimate goal of developing a set of standards for evaluating or measuring the potential benefits of new human error fixes.

Applying lessons learned to enhance human performance and reduce human error for ISS operations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nelson, W.R.

1999-01-01

A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy{close_quote}s Idaho National Engineering and Environmental Laboratory (INEEL) is developing a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper will describe previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS. {copyright} {ital 1999 American Institute of Physics.}« less

Applying lessons learned to enhance human performance and reduce human error for ISS operations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nelson, W.R.

1998-09-01

A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation ofmore » the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.« less

Structured methods for identifying and correcting potential human errors in aviation operations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nelson, W.R.

1997-10-01

Human errors have been identified as the source of approximately 60% of the incidents and accidents that occur in commercial aviation. It can be assumed that a very large number of human errors occur in aviation operations, even though in most cases the redundancies and diversities built into the design of aircraft systems prevent the errors from leading to serious consequences. In addition, when it is acknowledged that many system failures have their roots in human errors that occur in the design phase, it becomes apparent that the identification and elimination of potential human errors could significantly decrease the risksmore » of aviation operations. This will become even more critical during the design of advanced automation-based aircraft systems as well as next-generation systems for air traffic management. Structured methods to identify and correct potential human errors in aviation operations have been developed and are currently undergoing testing at the Idaho National Engineering and Environmental Laboratory (INEEL).« less

Human errors and violations in computer and information security: the viewpoint of network administrators and security specialists.

PubMed

Kraemer, Sara; Carayon, Pascale

2007-03-01

This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.

Intervention strategies for the management of human error

NASA Technical Reports Server (NTRS)

Wiener, Earl L.

1993-01-01

This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.

Exploring Reactions to Pilot Reliability Certification and Changing Attitudes on the Reduction of Errors

ERIC Educational Resources Information Center

Boedigheimer, Dan

2010-01-01

Approximately 70% of aviation accidents are attributable to human error. The greatest opportunity for further improving aviation safety is found in reducing human errors in the cockpit. The purpose of this quasi-experimental, mixed-method research was to evaluate whether there was a difference in pilot attitudes toward reducing human error in the…

Evaluating a medical error taxonomy.

PubMed

Brixey, Juliana; Johnson, Todd R; Zhang, Jiajie

2002-01-01

Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a standard language for reporting medication errors. This project maps the NCC MERP taxonomy of medication error to MedWatch medical errors involving infusion pumps. Of particular interest are human factors associated with medical device errors. The NCC MERP taxonomy of medication errors is limited in mapping information from MEDWATCH because of the focus on the medical device and the format of reporting.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

DOE Office of Scientific and Technical Information (OSTI.GOV)

Terezakis, Stephanie A., E-mail: stereza1@jhmi.edu; Harris, Kendra M.; Ford, Eric

Purpose: Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). Methods and Materials: All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface,more » (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Results: Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. Conclusions: A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.« less

Sleep quality, posttraumatic stress, depression, and human errors in train drivers: a population-based nationwide study in South Korea.

PubMed

Jeon, Hong Jin; Kim, Ji-Hae; Kim, Bin-Na; Park, Seung Jin; Fava, Maurizio; Mischoulon, David; Kang, Eun-Ho; Roh, Sungwon; Lee, Dongsoo

2014-12-01

Human error is defined as an unintended error that is attributable to humans rather than machines, and that is important to avoid to prevent accidents. We aimed to investigate the association between sleep quality and human errors among train drivers. Cross-sectional. Population-based. A sample of 5,480 subjects who were actively working as train drivers were recruited in South Korea. The participants were 4,634 drivers who completed all questionnaires (response rate 84.6%). None. The Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale-Revised (IES-R), the State-Trait Anxiety Inventory (STAI), and the Korean Occupational Stress Scale (KOSS). Of 4,634 train drivers, 349 (7.5%) showed more than one human error per 5 y. Human errors were associated with poor sleep quality, higher PSQI total scores, short sleep duration at night, and longer sleep latency. Among train drivers with poor sleep quality, those who experienced severe posttraumatic stress showed a significantly higher number of human errors than those without. Multiple logistic regression analysis showed that human errors were significantly associated with poor sleep quality and posttraumatic stress, whereas there were no significant associations with depression, trait and state anxiety, and work stress after adjusting for age, sex, education years, marital status, and career duration. Poor sleep quality was found to be associated with more human errors in train drivers, especially in those who experienced severe posttraumatic stress. © 2014 Associated Professional Sleep Societies, LLC.

Analyzing human errors in flight mission operations

NASA Technical Reports Server (NTRS)

Bruno, Kristin J.; Welz, Linda L.; Barnes, G. Michael; Sherif, Josef

1993-01-01

A long-term program is in progress at JPL to reduce cost and risk of flight mission operations through a defect prevention/error management program. The main thrust of this program is to create an environment in which the performance of the total system, both the human operator and the computer system, is optimized. To this end, 1580 Incident Surprise Anomaly reports (ISA's) from 1977-1991 were analyzed from the Voyager and Magellan projects. A Pareto analysis revealed that 38 percent of the errors were classified as human errors. A preliminary cluster analysis based on the Magellan human errors (204 ISA's) is presented here. The resulting clusters described the underlying relationships among the ISA's. Initial models of human error in flight mission operations are presented. Next, the Voyager ISA's will be scored and included in the analysis. Eventually, these relationships will be used to derive a theoretically motivated and empirically validated model of human error in flight mission operations. Ultimately, this analysis will be used to make continuous process improvements continuous process improvements to end-user applications and training requirements. This Total Quality Management approach will enable the management and prevention of errors in the future.

Human Error and the International Space Station: Challenges and Triumphs in Science Operations

NASA Technical Reports Server (NTRS)

Harris, Samantha S.; Simpson, Beau C.

2016-01-01

Any system with a human component is inherently risky. Studies in human factors and psychology have repeatedly shown that human operators will inevitably make errors, regardless of how well they are trained. Onboard the International Space Station (ISS) where crew time is arguably the most valuable resource, errors by the crew or ground operators can be costly to critical science objectives. Operations experts at the ISS Payload Operations Integration Center (POIC), located at NASA's Marshall Space Flight Center in Huntsville, Alabama, have learned that from payload concept development through execution, there are countless opportunities to introduce errors that can potentially result in costly losses of crew time and science. To effectively address this challenge, we must approach the design, testing, and operation processes with two specific goals in mind. First, a systematic approach to error and human centered design methodology should be implemented to minimize opportunities for user error. Second, we must assume that human errors will be made and enable rapid identification and recoverability when they occur. While a systematic approach and human centered development process can go a long way toward eliminating error, the complete exclusion of operator error is not a reasonable expectation. The ISS environment in particular poses challenging conditions, especially for flight controllers and astronauts. Operating a scientific laboratory 250 miles above the Earth is a complicated and dangerous task with high stakes and a steep learning curve. While human error is a reality that may never be fully eliminated, smart implementation of carefully chosen tools and techniques can go a long way toward minimizing risk and increasing the efficiency of NASA's space science operations.

Modeling human response errors in synthetic flight simulator domain

NASA Technical Reports Server (NTRS)

Ntuen, Celestine A.

1992-01-01

This paper presents a control theoretic approach to modeling human response errors (HRE) in the flight simulation domain. The human pilot is modeled as a supervisor of a highly automated system. The synthesis uses the theory of optimal control pilot modeling for integrating the pilot's observation error and the error due to the simulation model (experimental error). Methods for solving the HRE problem are suggested. Experimental verification of the models will be tested in a flight quality handling simulation.

Defining the Relationship Between Human Error Classes and Technology Intervention Strategies

NASA Technical Reports Server (NTRS)

Wiegmann, Douglas A.; Rantanen, Esa; Crisp, Vicki K. (Technical Monitor)

2002-01-01

One of the main factors in all aviation accidents is human error. The NASA Aviation Safety Program (AvSP), therefore, has identified several human-factors safety technologies to address this issue. Some technologies directly address human error either by attempting to reduce the occurrence of errors or by mitigating the negative consequences of errors. However, new technologies and system changes may also introduce new error opportunities or even induce different types of errors. Consequently, a thorough understanding of the relationship between error classes and technology "fixes" is crucial for the evaluation of intervention strategies outlined in the AvSP, so that resources can be effectively directed to maximize the benefit to flight safety. The purpose of the present project, therefore, was to examine the repositories of human factors data to identify the possible relationship between different error class and technology intervention strategies. The first phase of the project, which is summarized here, involved the development of prototype data structures or matrices that map errors onto "fixes" (and vice versa), with the hope of facilitating the development of standards for evaluating safety products. Possible follow-on phases of this project are also discussed. These additional efforts include a thorough and detailed review of the literature to fill in the data matrix and the construction of a complete database and standards checklists.

Development and implementation of a human accuracy program in patient foodservice.

PubMed

Eden, S H; Wood, S M; Ptak, K M

1987-04-01

For many years, industry has utilized the concept of human error rates to monitor and minimize human errors in the production process. A consistent quality-controlled product increases consumer satisfaction and repeat purchase of product. Administrative dietitians have applied the concepts of using human error rates (the number of errors divided by the number of opportunities for error) at four hospitals, with a total bed capacity of 788, within a tertiary-care medical center. Human error rate was used to monitor and evaluate trayline employee performance and to evaluate layout and tasks of trayline stations, in addition to evaluating employees in patient service areas. Long-term employees initially opposed the error rate system with some hostility and resentment, while newer employees accepted the system. All employees now believe that the constant feedback given by supervisors enhances their self-esteem and productivity. Employee error rates are monitored daily and are used to counsel employees when necessary; they are also utilized during annual performance evaluation. Average daily error rates for a facility staffed by new employees decreased from 7% to an acceptable 3%. In a facility staffed by long-term employees, the error rate increased, reflecting improper error documentation. Patient satisfaction surveys reveal satisfaction, for tray accuracy increased from 88% to 92% in the facility staffed by long-term employees and has remained above the 90% standard in the facility staffed by new employees.

Reflections on human error - Matters of life and death

NASA Technical Reports Server (NTRS)

Wiener, Earl L.

1989-01-01

The last two decades have witnessed a rapid growth in the introduction of automatic devices into aircraft cockpits, and eleswhere in human-machine systems. This was motivated in part by the assumption that when human functioning is replaced by machine functioning, human error is eliminated. Experience to date shows that this is far from true, and that automation does not replace humans, but changes their role in the system, as well as the types and severity of the errors they make. This altered role may lead to fewer, but more critical errors. Intervention strategies to prevent these errors, or ameliorate their consequences include basic human factors engineering of the interface, enhanced warning and alerting systems, and more intelligent interfaces that understand the strategic intent of the crew and can detect and trap inconsistent or erroneous input before it affects the system.

A stochastic dynamic model for human error analysis in nuclear power plants

NASA Astrophysics Data System (ADS)

Delgado-Loperena, Dharma

Nuclear disasters like Three Mile Island and Chernobyl indicate that human performance is a critical safety issue, sending a clear message about the need to include environmental press and competence aspects in research. This investigation was undertaken to serve as a roadmap for studying human behavior through the formulation of a general solution equation. The theoretical model integrates models from two heretofore-disassociated disciplines (behavior specialists and technical specialists), that historically have independently studied the nature of error and human behavior; including concepts derived from fractal and chaos theory; and suggests re-evaluation of base theory regarding human error. The results of this research were based on comprehensive analysis of patterns of error, with the omnipresent underlying structure of chaotic systems. The study of patterns lead to a dynamic formulation, serving for any other formula used to study human error consequences. The search for literature regarding error yielded insight for the need to include concepts rooted in chaos theory and strange attractors---heretofore unconsidered by mainstream researchers who investigated human error in nuclear power plants or those who employed the ecological model in their work. The study of patterns obtained from the rupture of a steam generator tube (SGTR) event simulation, provided a direct application to aspects of control room operations in nuclear power plant operations. In doing so, the conceptual foundation based in the understanding of the patterns of human error analysis can be gleaned, resulting in reduced and prevent undesirable events.

Human factors process failure modes and effects analysis (HF PFMEA) software tool

NASA Technical Reports Server (NTRS)

Chandler, Faith T. (Inventor); Relvini, Kristine M. (Inventor); Shedd, Nathaneal P. (Inventor); Valentino, William D. (Inventor); Philippart, Monica F. (Inventor); Bessette, Colette I. (Inventor)

2011-01-01

Methods, computer-readable media, and systems for automatically performing Human Factors Process Failure Modes and Effects Analysis for a process are provided. At least one task involved in a process is identified, where the task includes at least one human activity. The human activity is described using at least one verb. A human error potentially resulting from the human activity is automatically identified, the human error is related to the verb used in describing the task. A likelihood of occurrence, detection, and correction of the human error is identified. The severity of the effect of the human error is identified. The likelihood of occurrence, and the severity of the risk of potential harm is identified. The risk of potential harm is compared with a risk threshold to identify the appropriateness of corrective measures.

Air Force Academy Homepage

Science.gov Websites

Chaplain Corps Cadet Chapel Community Center Chapel Institutional Review Board Not Human Subjects Research Requirements 7 Not Human Subjects Research Form 8 Researcher Instructions - Activities Submitted to DoD IRB 9 Review 18 Not Human Subjects Errors 19 Exempt Research Most Frequent Errors 20 Most Frequent Errors for

Development of an FAA-EUROCONTROL technique for the analysis of human error in ATM : final report.

DOT National Transportation Integrated Search

2002-07-01

Human error has been identified as a dominant risk factor in safety-oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current air traffic management (ATM) systems. The first s...

Human Error: The Stakes Are Raised.

ERIC Educational Resources Information Center

Greenberg, Joel

1980-01-01

Mistakes related to the operation of nuclear power plants and other technologically complex systems are discussed. Recommendations are given for decreasing the chance of human error in the operation of nuclear plants. The causes of the Three Mile Island incident are presented in terms of the human error element. (SA)

Avoiding Human Error in Mission Operations: Cassini Flight Experience

NASA Technical Reports Server (NTRS)

Burk, Thomas A.

2012-01-01

Operating spacecraft is a never-ending challenge and the risk of human error is ever- present. Many missions have been significantly affected by human error on the part of ground controllers. The Cassini mission at Saturn has not been immune to human error, but Cassini operations engineers use tools and follow processes that find and correct most human errors before they reach the spacecraft. What is needed are skilled engineers with good technical knowledge, good interpersonal communications, quality ground software, regular peer reviews, up-to-date procedures, as well as careful attention to detail and the discipline to test and verify all commands that will be sent to the spacecraft. Two areas of special concern are changes to flight software and response to in-flight anomalies. The Cassini team has a lot of practical experience in all these areas and they have found that well-trained engineers with good tools who follow clear procedures can catch most errors before they get into command sequences to be sent to the spacecraft. Finally, having a robust and fault-tolerant spacecraft that allows ground controllers excellent visibility of its condition is the most important way to ensure human error does not compromise the mission.

Good people who try their best can have problems: recognition of human factors and how to minimise error.

PubMed

Brennan, Peter A; Mitchell, David A; Holmes, Simon; Plint, Simon; Parry, David

2016-01-01

Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"? Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors.

PubMed

Roth, Cheryl; Brewer, Melanie; Wieck, K Lynn

2017-07-01

The purpose of this study was to identify human factors associated with nursing errors. Using a Delphi technique, this study used feedback from a panel of nurse experts (n = 25) on an initial qualitative survey questionnaire followed by summarizing the results with feedback and confirmation. Synthesized factors regarding causes of errors were incorporated into a quantitative Likert-type scale, and the original expert panel participants were queried a second time to validate responses. The list identified 24 items as most common causes of nursing errors, including swamping and errors made by others that nurses are expected to recognize and fix. The responses provided a consensus top 10 errors list based on means with heavy workload and fatigue at the top of the list. The use of the Delphi survey established consensus and developed a platform upon which future study of nursing errors can evolve as a link to future solutions. This list of human factors in nursing errors should serve to stimulate dialogue among nurses about how to prevent errors and improve outcomes. Human and system failures have been the subject of an abundance of research, yet nursing errors continue to occur. © 2016 Wiley Periodicals, Inc.

FRamework Assessing Notorious Contributing Influences for Error (FRANCIE): Perspective on Taxonomy Development to Support Error Reporting and Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lon N. Haney; David I. Gertman

2003-04-01

Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human errormore » analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.« less

Analysis of measured data of human body based on error correcting frequency

NASA Astrophysics Data System (ADS)

Jin, Aiyan; Peipei, Gao; Shang, Xiaomei

2014-04-01

Anthropometry is to measure all parts of human body surface, and the measured data is the basis of analysis and study of the human body, establishment and modification of garment size and formulation and implementation of online clothing store. In this paper, several groups of the measured data are gained, and analysis of data error is gotten by analyzing the error frequency and using analysis of variance method in mathematical statistics method. Determination of the measured data accuracy and the difficulty of measured parts of human body, further studies of the causes of data errors, and summarization of the key points to minimize errors possibly are also mentioned in the paper. This paper analyses the measured data based on error frequency, and in a way , it provides certain reference elements to promote the garment industry development.

Tailoring a Human Reliability Analysis to Your Industry Needs

NASA Technical Reports Server (NTRS)

DeMott, D. L.

2016-01-01

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed versus a requirement to provide a numerical value as part of a probabilistic risk assessment. Industries involved with humans operating large equipment or transport systems (ex. railroads or airlines) would have more need to address the man machine interface than medical workers administering medications. Human error occurs in every industry; in most cases the consequences are relatively benign and occasionally beneficial. In cases where the results can have disastrous consequences, the use of Human Reliability techniques to identify and classify the risk of human errors allows a company more opportunities to mitigate or eliminate these types of risks and prevent costly tragedies.

Using APEX to Model Anticipated Human Error: Analysis of a GPS Navigational Aid

NASA Technical Reports Server (NTRS)

VanSelst, Mark; Freed, Michael; Shefto, Michael (Technical Monitor)

1997-01-01

The interface development process can be dramatically improved by predicting design facilitated human error at an early stage in the design process. The approach we advocate is to SIMULATE the behavior of a human agent carrying out tasks with a well-specified user interface, ANALYZE the simulation for instances of human error, and then REFINE the interface or protocol to minimize predicted error. This approach, incorporated into the APEX modeling architecture, differs from past approaches to human simulation in Its emphasis on error rather than e.g. learning rate or speed of response. The APEX model consists of two major components: (1) a powerful action selection component capable of simulating behavior in complex, multiple-task environments; and (2) a resource architecture which constrains cognitive, perceptual, and motor capabilities to within empirically demonstrated limits. The model mimics human errors arising from interactions between limited human resources and elements of the computer interface whose design falls to anticipate those limits. We analyze the design of a hand-held Global Positioning System (GPS) device used for radical and navigational decisions in small yacht recalls. The analysis demonstrates how human system modeling can be an effective design aid, helping to accelerate the process of refining a product (or procedure).

Exploring human error in military aviation flight safety events using post-incident classification systems.

PubMed

Hooper, Brionny J; O'Hare, David P A

2013-08-01

Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.

The application of SHERPA (Systematic Human Error Reduction and Prediction Approach) in the development of compensatory cognitive rehabilitation strategies for stroke patients with left and right brain damage.

PubMed

Hughes, Charmayne M L; Baber, Chris; Bienkiewicz, Marta; Worthington, Andrew; Hazell, Alexa; Hermsdörfer, Joachim

2015-01-01

Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.

An Analysis of U.S. Army Fratricide Incidents during the Global War on Terror (11 September 2001 to 31 March 2008)

DTIC Science & Technology

2010-03-15

Swiss cheese model of human error causation. ................................................................... 3  2. Results for the classification of...based on Reason’s “ Swiss cheese ” model of human error (1990). Figure 1 describes how an accident is likely to occur when all of the errors, or “holes...align. A detailed description of HFACS can be found in Wiegmann and Shappell (2003). Figure 1. The Swiss cheese model of human error

A Quality Improvement Project to Decrease Human Milk Errors in the NICU.

PubMed

Oza-Frank, Reena; Kachoria, Rashmi; Dail, James; Green, Jasmine; Walls, Krista; McClead, Richard E

2017-02-01

Ensuring safe human milk in the NICU is a complex process with many potential points for error, of which one of the most serious is administration of the wrong milk to the wrong infant. Our objective was to describe a quality improvement initiative that was associated with a reduction in human milk administration errors identified over a 6-year period in a typical, large NICU setting. We employed a quasi-experimental time series quality improvement initiative by using tools from the model for improvement, Six Sigma methodology, and evidence-based interventions. Scanned errors were identified from the human milk barcode medication administration system. Scanned errors of interest were wrong-milk-to-wrong-infant, expired-milk, or preparation errors. The scanned error rate and the impact of additional improvement interventions from 2009 to 2015 were monitored by using statistical process control charts. From 2009 to 2015, the total number of errors scanned declined from 97.1 per 1000 bottles to 10.8. Specifically, the number of expired milk error scans declined from 84.0 per 1000 bottles to 8.9. The number of preparation errors (4.8 per 1000 bottles to 2.2) and wrong-milk-to-wrong-infant errors scanned (8.3 per 1000 bottles to 2.0) also declined. By reducing the number of errors scanned, the number of opportunities for errors also decreased. Interventions that likely had the greatest impact on reducing the number of scanned errors included installation of bedside (versus centralized) scanners and dedicated staff to handle milk. Copyright © 2017 by the American Academy of Pediatrics.

Human errors and measurement uncertainty

NASA Astrophysics Data System (ADS)

Kuselman, Ilya; Pennecchi, Francesca

2015-04-01

Evaluating the residual risk of human errors in a measurement and testing laboratory, remaining after the error reduction by the laboratory quality system, and quantifying the consequences of this risk for the quality of the measurement/test results are discussed based on expert judgments and Monte Carlo simulations. A procedure for evaluation of the contribution of the residual risk to the measurement uncertainty budget is proposed. Examples are provided using earlier published sets of expert judgments on human errors in pH measurement of groundwater, elemental analysis of geological samples by inductively coupled plasma mass spectrometry, and multi-residue analysis of pesticides in fruits and vegetables. The human error contribution to the measurement uncertainty budget in the examples was not negligible, yet also not dominant. This was assessed as a good risk management result.

Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

DOE Office of Scientific and Technical Information (OSTI.GOV)

Callan, J.R.; Kelly, R.T.; Quinn, M.L.

1995-05-01

Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices usedmore » in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error.« less

Human error analysis of commercial aviation accidents using the human factors analysis and classification system (HFACS)

DOT National Transportation Integrated Search

2001-02-01

The Human Factors Analysis and Classification System (HFACS) is a general human error framework : originally developed and tested within the U.S. military as a tool for investigating and analyzing the human : causes of aviation accidents. Based upon ...

Compound Stimulus Presentation Does Not Deepen Extinction in Human Causal Learning

PubMed Central

Griffiths, Oren; Holmes, Nathan; Westbrook, R. Fred

2017-01-01

Models of associative learning have proposed that cue-outcome learning critically depends on the degree of prediction error encountered during training. Two experiments examined the role of error-driven extinction learning in a human causal learning task. Target cues underwent extinction in the presence of additional cues, which differed in the degree to which they predicted the outcome, thereby manipulating outcome expectancy and, in the absence of any change in reinforcement, prediction error. These prediction error manipulations have each been shown to modulate extinction learning in aversive conditioning studies. While both manipulations resulted in increased prediction error during training, neither enhanced extinction in the present human learning task (one manipulation resulted in less extinction at test). The results are discussed with reference to the types of associations that are regulated by prediction error, the types of error terms involved in their regulation, and how these interact with parameters involved in training. PMID:28232809

Human errors and occupational injuries of older female workers in the residential healthcare facilities for the elderly.

PubMed

Kim, Jun Sik; Jeong, Byung Yong

2018-05-03

The study aimed to describe the characteristics of occupational injuries of female workers in the residential healthcare facilities for the elderly, and analyze human errors as causes of accidents. From the national industrial accident compensation data, 506 female injuries were analyzed by age and occupation. The results showed that medical service worker was the most prevalent (54.1%), followed by social welfare worker (20.4%). Among injuries, 55.7% were <1 year of work experience, and 37.9% were ≥60 years old. Slips/falls were the most common type of accident (42.7%), and proportion of injured by slips/falls increases with age. Among human errors, action errors were the primary reasons, followed by perception errors, and cognition errors. Besides, the ratios of injuries by perception errors and action errors increase with age, respectively. The findings of this study suggest that there is a need to design workplaces that accommodate the characteristics of older female workers.

[Risk and risk management in aviation].

PubMed

Müller, Manfred

2004-10-01

RISK MANAGEMENT: The large proportion of human errors in aviation accidents suggested the solution--at first sight brilliant--to replace the fallible human being by an "infallible" digitally-operating computer. However, even after the introduction of the so-called HITEC-airplanes, the factor human error still accounts for 75% of all accidents. Thus, if the computer is ruled out as the ultimate safety system, how else can complex operations involving quick and difficult decisions be controlled? OPTIMIZED TEAM INTERACTION/PARALLEL CONNECTION OF THOUGHT MACHINES: Since a single person is always "highly error-prone", support and control have to be guaranteed by a second person. The independent work of mind results in a safety network that more efficiently cushions human errors. NON-PUNITIVE ERROR MANAGEMENT: To be able to tackle the actual problems, the open discussion of intervened errors must not be endangered by the threat of punishment. It has been shown in the past that progress is primarily achieved by investigating and following up mistakes, failures and catastrophes shortly after they happened. HUMAN FACTOR RESEARCH PROJECT: A comprehensive survey showed the following result: By far the most frequent safety-critical situation (37.8% of all events) consists of the following combination of risk factors: 1. A complication develops. 2. In this situation of increased stress a human error occurs. 3. The negative effects of the error cannot be corrected or eased because there are deficiencies in team interaction on the flight deck. This means, for example, that a negative social climate has the effect of a "turbocharger" when a human error occurs. It needs to be pointed out that a negative social climate is not identical with a dispute. In many cases the working climate is burdened without the responsible person even noticing it: A first negative impression, too much or too little respect, contempt, misunderstandings, not expressing unclear concern, etc. can considerably reduce the efficiency of a team.

Competition between learned reward and error outcome predictions in anterior cingulate cortex.

PubMed

Alexander, William H; Brown, Joshua W

2010-02-15

The anterior cingulate cortex (ACC) is implicated in performance monitoring and cognitive control. Non-human primate studies of ACC show prominent reward signals, but these are elusive in human studies, which instead show mainly conflict and error effects. Here we demonstrate distinct appetitive and aversive activity in human ACC. The error likelihood hypothesis suggests that ACC activity increases in proportion to the likelihood of an error, and ACC is also sensitive to the consequence magnitude of the predicted error. Previous work further showed that error likelihood effects reach a ceiling as the potential consequences of an error increase, possibly due to reductions in the average reward. We explored this issue by independently manipulating reward magnitude of task responses and error likelihood while controlling for potential error consequences in an Incentive Change Signal Task. The fMRI results ruled out a modulatory effect of expected reward on error likelihood effects in favor of a competition effect between expected reward and error likelihood. Dynamic causal modeling showed that error likelihood and expected reward signals are intrinsic to the ACC rather than received from elsewhere. These findings agree with interpretations of ACC activity as signaling both perceptions of risk and predicted reward. Copyright 2009 Elsevier Inc. All rights reserved.

Temporal uncertainty analysis of human errors based on interrelationships among multiple factors: a case of Minuteman III missile accident.

PubMed

Rong, Hao; Tian, Jin; Zhao, Tingdi

2016-01-01

In traditional approaches of human reliability assessment (HRA), the definition of the error producing conditions (EPCs) and the supporting guidance are such that some of the conditions (especially organizational or managerial conditions) can hardly be included, and thus the analysis is burdened with incomprehensiveness without reflecting the temporal trend of human reliability. A method based on system dynamics (SD), which highlights interrelationships among technical and organizational aspects that may contribute to human errors, is presented to facilitate quantitatively estimating the human error probability (HEP) and its related variables changing over time in a long period. Taking the Minuteman III missile accident in 2008 as a case, the proposed HRA method is applied to assess HEP during missile operations over 50 years by analyzing the interactions among the variables involved in human-related risks; also the critical factors are determined in terms of impact that the variables have on risks in different time periods. It is indicated that both technical and organizational aspects should be focused on to minimize human errors in a long run. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Systematic analysis of video data from different human-robot interaction studies: a categorization of social signals during error situations.

PubMed

Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred

2015-01-01

Human-robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human-robot interaction experiments. For that, we analyzed 201 videos of five human-robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human-robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies.

Human error analysis of commercial aviation accidents: application of the Human Factors Analysis and Classification system (HFACS).

PubMed

Wiegmann, D A; Shappell, S A

2001-11-01

The Human Factors Analysis and Classification System (HFACS) is a general human error framework originally developed and tested within the U.S. military as a tool for investigating and analyzing the human causes of aviation accidents. Based on Reason's (1990) model of latent and active failures, HFACS addresses human error at all levels of the system, including the condition of aircrew and organizational factors. The purpose of the present study was to assess the utility of the HFACS framework as an error analysis and classification tool outside the military. The HFACS framework was used to analyze human error data associated with aircrew-related commercial aviation accidents that occurred between January 1990 and December 1996 using database records maintained by the NTSB and the FAA. Investigators were able to reliably accommodate all the human causal factors associated with the commercial aviation accidents examined in this study using the HFACS system. In addition, the classification of data using HFACS highlighted several critical safety issues in need of intervention research. These results demonstrate that the HFACS framework can be a viable tool for use within the civil aviation arena. However, additional research is needed to examine its applicability to areas outside the flight deck, such as aircraft maintenance and air traffic control domains.

To Err Is Human; To Structurally Prime from Errors Is Also Human

ERIC Educational Resources Information Center

Slevc, L. Robert; Ferreira, Victor S.

2013-01-01

Natural language contains disfluencies and errors. Do listeners simply discard information that was clearly produced in error, or can erroneous material persist to affect subsequent processing? Two experiments explored this question using a structural priming paradigm. Speakers described dative-eliciting pictures after hearing prime sentences that…

Human factors analysis and classification system-HFACS.

DOT National Transportation Integrated Search

2000-02-01

Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident : reporting systems are not designed around any theoretical framework of human error. As a result, most : accident databases are not conduci...

Technical approaches for measurement of human errors

NASA Technical Reports Server (NTRS)

Clement, W. F.; Heffley, R. K.; Jewell, W. F.; Mcruer, D. T.

1980-01-01

Human error is a significant contributing factor in a very high proportion of civil transport, general aviation, and rotorcraft accidents. The technical details of a variety of proven approaches for the measurement of human errors in the context of the national airspace system are presented. Unobtrusive measurements suitable for cockpit operations and procedures in part of full mission simulation are emphasized. Procedure, system performance, and human operator centered measurements are discussed as they apply to the manual control, communication, supervisory, and monitoring tasks which are relevant to aviation operations.

The dynamics of error processing in the human brain as reflected by high-gamma activity in noninvasive and intracranial EEG.

PubMed

Völker, Martin; Fiederer, Lukas D J; Berberich, Sofie; Hammer, Jiří; Behncke, Joos; Kršek, Pavel; Tomášek, Martin; Marusič, Petr; Reinacher, Peter C; Coenen, Volker A; Helias, Moritz; Schulze-Bonhage, Andreas; Burgard, Wolfram; Ball, Tonio

2018-06-01

Error detection in motor behavior is a fundamental cognitive function heavily relying on local cortical information processing. Neural activity in the high-gamma frequency band (HGB) closely reflects such local cortical processing, but little is known about its role in error processing, particularly in the healthy human brain. Here we characterize the error-related response of the human brain based on data obtained with noninvasive EEG optimized for HGB mapping in 31 healthy subjects (15 females, 16 males), and additional intracranial EEG data from 9 epilepsy patients (4 females, 5 males). Our findings reveal a multiscale picture of the global and local dynamics of error-related HGB activity in the human brain. On the global level as reflected in the noninvasive EEG, the error-related response started with an early component dominated by anterior brain regions, followed by a shift to parietal regions, and a subsequent phase characterized by sustained parietal HGB activity. This phase lasted for more than 1 s after the error onset. On the local level reflected in the intracranial EEG, a cascade of both transient and sustained error-related responses involved an even more extended network, spanning beyond frontal and parietal regions to the insula and the hippocampus. HGB mapping appeared especially well suited to investigate late, sustained components of the error response, possibly linked to downstream functional stages such as error-related learning and behavioral adaptation. Our findings establish the basic spatio-temporal properties of HGB activity as a neural correlate of error processing, complementing traditional error-related potential studies. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Development of an errorable car-following driver model

NASA Astrophysics Data System (ADS)

Yang, H.-H.; Peng, H.

2010-06-01

An errorable car-following driver model is presented in this paper. An errorable driver model is one that emulates human driver's functions and can generate both nominal (error-free), as well as devious (with error) behaviours. This model was developed for evaluation and design of active safety systems. The car-following data used for developing and validating the model were obtained from a large-scale naturalistic driving database. The stochastic car-following behaviour was first analysed and modelled as a random process. Three error-inducing behaviours were then introduced. First, human perceptual limitation was studied and implemented. Distraction due to non-driving tasks was then identified based on the statistical analysis of the driving data. Finally, time delay of human drivers was estimated through a recursive least-square identification process. By including these three error-inducing behaviours, rear-end collisions with the lead vehicle could occur. The simulated crash rate was found to be similar but somewhat higher than that reported in traffic statistics.

Lost in Translation: the Case for Integrated Testing

NASA Technical Reports Server (NTRS)

Young, Aaron

2017-01-01

The building of a spacecraft is complex and often involves multiple suppliers and companies that have their own designs and processes. Standards have been developed across the industries to reduce the chances for critical flight errors at the system level, but the spacecraft is still vulnerable to the introduction of critical errors during integration of these systems. Critical errors can occur at any time during the process and in many cases, human reliability analysis (HRA) identifies human error as a risk driver. Most programs have a test plan in place that is intended to catch these errors, but it is not uncommon for schedule and cost stress to result in less testing than initially planned. Therefore, integrated testing, or "testing as you fly," is essential as a final check on the design and assembly to catch any errors prior to the mission. This presentation will outline the unique benefits of integrated testing by catching critical flight errors that can otherwise go undetected, discuss HRA methods that are used to identify opportunities for human error, lessons learned and challenges over ownership of testing will be discussed.

Human factors in aircraft incidents - Results of a 7-year study (Andre Allard Memorial Lecture)

NASA Technical Reports Server (NTRS)

Billings, C. E.; Reynard, W. D.

1984-01-01

It is pointed out that nearly all fatal aircraft accidents are preventable, and that most such accidents are due to human error. The present discussion is concerned with the results of a seven-year study of the data collected by the NASA Aviation Safety Reporting System (ASRS). The Aviation Safety Reporting System was designed to stimulate as large a flow as possible of information regarding errors and operational problems in the conduct of air operations. It was implemented in April, 1976. In the following 7.5 years, 35,000 reports have been received from pilots, controllers, and the armed forces. Human errors are found in more than 80 percent of these reports. Attention is given to the types of events reported, possible causal factors in incidents, the relationship of incidents and accidents, and sources of error in the data. ASRS reports include sufficient detail to permit authorities to institute changes in the national aviation system designed to minimize the likelihood of human error, and to insulate the system against the effects of errors.

Human factors in surgery: from Three Mile Island to the operating room.

PubMed

D'Addessi, Alessandro; Bongiovanni, Luca; Volpe, Andrea; Pinto, Francesco; Bassi, PierFrancesco

2009-01-01

Human factors is a definition that includes the science of understanding the properties of human capability, the application of this understanding to the design and development of systems and services, the art of ensuring their successful applications to a program. The field of human factors traces its origins to the Second World War, but Three Mile Island has been the best example of how groups of people react and make decisions under stress: this nuclear accident was exacerbated by wrong decisions made because the operators were overwhelmed with irrelevant, misleading or incorrect information. Errors and their nature are the same in all human activities. The predisposition for error is so intrinsic to human nature that scientifically it is best considered as inherently biologic. The causes of error in medical care may not be easily generalized. Surgery differs in important ways: most errors occur in the operating room and are technical in nature. Commonly, surgical error has been thought of as the consequence of lack of skill or ability, and is the result of thoughtless actions. Moreover the 'operating theatre' has a unique set of team dynamics: professionals from multiple disciplines are required to work in a closely coordinated fashion. This complex environment provides multiple opportunities for unclear communication, clashing motivations, errors arising not from technical incompetence but from poor interpersonal skills. Surgeons have to work closely with human factors specialists in future studies. By improving processes already in place in many operating rooms, safety will be enhanced and quality increased.

The Human Factors Analysis and Classification System : HFACS : final report.

DOT National Transportation Integrated Search

2000-02-01

Human error has been implicated in 70 to 80% of all civil and military aviation accidents. Yet, most accident reporting systems are not designed around any theoretical framework of human error. As a result, most accident databases are not conducive t...

Differential reliance of chimpanzees and humans on automatic and deliberate control of motor actions.

PubMed

Kaneko, Takaaki; Tomonaga, Masaki

2014-06-01

Humans are often unaware of how they control their limb motor movements. People pay attention to their own motor movements only when their usual motor routines encounter errors. Yet little is known about the extent to which voluntary actions rely on automatic control and when automatic control shifts to deliberate control in nonhuman primates. In this study, we demonstrate that chimpanzees and humans showed similar limb motor adjustment in response to feedback error during reaching actions, whereas attentional allocation inferred from gaze behavior differed. We found that humans shifted attention to their own motor kinematics as errors were induced in motor trajectory feedback regardless of whether the errors actually disrupted their reaching their action goals. In contrast, chimpanzees shifted attention to motor execution only when errors actually interfered with their achieving a planned action goal. These results indicate that the species differed in their criteria for shifting from automatic to deliberate control of motor actions. It is widely accepted that sophisticated motor repertoires have evolved in humans. Our results suggest that the deliberate monitoring of one's own motor kinematics may have evolved in the human lineage. Copyright © 2014 Elsevier B.V. All rights reserved.

Preventable Medical Errors Driven Modeling of Medical Best Practice Guidance Systems.

PubMed

Ou, Andrew Y-Z; Jiang, Yu; Wu, Po-Liang; Sha, Lui; Berlin, Richard B

2017-01-01

In a medical environment such as Intensive Care Unit, there are many possible reasons to cause errors, and one important reason is the effect of human intellectual tasks. When designing an interactive healthcare system such as medical Cyber-Physical-Human Systems (CPHSystems), it is important to consider whether the system design can mitigate the errors caused by these tasks or not. In this paper, we first introduce five categories of generic intellectual tasks of humans, where tasks among each category may lead to potential medical errors. Then, we present an integrated modeling framework to model a medical CPHSystem and use UPPAAL as the foundation to integrate and verify the whole medical CPHSystem design models. With a verified and comprehensive model capturing the human intellectual tasks effects, we can design a more accurate and acceptable system. We use a cardiac arrest resuscitation guidance and navigation system (CAR-GNSystem) for such medical CPHSystem modeling. Experimental results show that the CPHSystem models help determine system design flaws and can mitigate the potential medical errors caused by the human intellectual tasks.

Modeling human tracking error in several different anti-tank systems

NASA Technical Reports Server (NTRS)

Kleinman, D. L.

1981-01-01

An optimal control model for generating time histories of human tracking errors in antitank systems is outlined. Monte Carlo simulations of human operator responses for three Army antitank systems are compared. System/manipulator dependent data comparisons reflecting human operator limitations in perceiving displayed quantities and executing intended control motions are presented. Motor noise parameters are also discussed.

[Using some modern mathematical models of postmortem cooling of the human body for the time of death determination].

PubMed

Vavilov, A Iu; Viter, V I

2007-01-01

Mathematical questions of data errors of modern thermometrical models of postmortem cooling of the human body are considered. The main diagnostic areas used for thermometry are analyzed to minimize these data errors. The authors propose practical recommendations to decrease data errors of determination of prescription of death coming.

The Hinton train disaster.

PubMed

Smiley, A M

1990-10-01

In February of 1986 a head-on collision occurred between a freight train and a passenger train in western Canada killing 23 people and causing over $30 million of damage. A Commission of Inquiry appointed by the Canadian government concluded that human error was the major reason for the collision. This report discusses the factors contributing to the human error: mainly poor work-rest schedules, the monotonous nature of the train driving task, insufficient information about train movements, and the inadequate backup systems in case of human error.

A Conceptual Framework for Predicting Error in Complex Human-Machine Environments

NASA Technical Reports Server (NTRS)

Freed, Michael; Remington, Roger; Null, Cynthia H. (Technical Monitor)

1998-01-01

We present a Goals, Operators, Methods, and Selection Rules-Model Human Processor (GOMS-MHP) style model-based approach to the problem of predicting human habit capture errors. Habit captures occur when the model fails to allocate limited cognitive resources to retrieve task-relevant information from memory. Lacking the unretrieved information, decision mechanisms act in accordance with implicit default assumptions, resulting in error when relied upon assumptions prove incorrect. The model helps interface designers identify situations in which such failures are especially likely.

STAMP-Based HRA Considering Causality Within a Sociotechnical System: A Case of Minuteman III Missile Accident.

PubMed

Rong, Hao; Tian, Jin

2015-05-01

The study contributes to human reliability analysis (HRA) by proposing a method that focuses more on human error causality within a sociotechnical system, illustrating its rationality and feasibility by using a case of the Minuteman (MM) III missile accident. Due to the complexity and dynamics within a sociotechnical system, previous analyses of accidents involving human and organizational factors clearly demonstrated that the methods using a sequential accident model are inadequate to analyze human error within a sociotechnical system. System-theoretic accident model and processes (STAMP) was used to develop a universal framework of human error causal analysis. To elaborate the causal relationships and demonstrate the dynamics of human error, system dynamics (SD) modeling was conducted based on the framework. A total of 41 contributing factors, categorized into four types of human error, were identified through the STAMP-based analysis. All factors are related to a broad view of sociotechnical systems, and more comprehensive than the causation presented in the accident investigation report issued officially. Recommendations regarding both technical and managerial improvement for a lower risk of the accident are proposed. The interests of an interdisciplinary approach provide complementary support between system safety and human factors. The integrated method based on STAMP and SD model contributes to HRA effectively. The proposed method will be beneficial to HRA, risk assessment, and control of the MM III operating process, as well as other sociotechnical systems. © 2014, Human Factors and Ergonomics Society.

Nature of the refractive errors in rhesus monkeys (Macaca mulatta) with experimentally induced ametropias.

PubMed

Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-Su; Ramamirtham, Ramkumar; Smith, Earl L

2010-08-23

We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. Copyright 2010 Elsevier Ltd. All rights reserved.

Nature of the Refractive Errors in Rhesus Monkeys (Macaca mulatta) with Experimentally Induced Ametropias

PubMed Central

Qiao-Grider, Ying; Hung, Li-Fang; Kee, Chea-su; Ramamirtham, Ramkumar; Smith, Earl L.

2010-01-01

We analyzed the contribution of individual ocular components to vision-induced ametropias in 210 rhesus monkeys. The primary contribution to refractive-error development came from vitreous chamber depth; a minor contribution from corneal power was also detected. However, there was no systematic relationship between refractive error and anterior chamber depth or between refractive error and any crystalline lens parameter. Our results are in good agreement with previous studies in humans, suggesting that the refractive errors commonly observed in humans are created by vision-dependent mechanisms that are similar to those operating in monkeys. This concordance emphasizes the applicability of rhesus monkeys in refractive-error studies. PMID:20600237

Human Error as an Emergent Property of Action Selection and Task Place-Holding.

PubMed

Tamborello, Franklin P; Trafton, J Gregory

2017-05-01

A computational process model could explain how the dynamic interaction of human cognitive mechanisms produces each of multiple error types. With increasing capability and complexity of technological systems, the potential severity of consequences of human error is magnified. Interruption greatly increases people's error rates, as does the presence of other information to maintain in an active state. The model executed as a software-instantiated Monte Carlo simulation. It drew on theoretical constructs such as associative spreading activation for prospective memory, explicit rehearsal strategies as a deliberate cognitive operation to aid retrospective memory, and decay. The model replicated the 30% effect of interruptions on postcompletion error in Ratwani and Trafton's Stock Trader task, the 45% interaction effect on postcompletion error of working memory capacity and working memory load from Byrne and Bovair's Phaser Task, as well as the 5% perseveration and 3% omission effects of interruption from the UNRAVEL Task. Error classes including perseveration, omission, and postcompletion error fall naturally out of the theory. The model explains post-interruption error in terms of task state representation and priming for recall of subsequent steps. Its performance suggests that task environments providing more cues to current task state will mitigate error caused by interruption. For example, interfaces could provide labeled progress indicators or facilities for operators to quickly write notes about their task states when interrupted.

Simultaneous Control of Error Rates in fMRI Data Analysis

PubMed Central

Kang, Hakmook; Blume, Jeffrey; Ombao, Hernando; Badre, David

2015-01-01

The key idea of statistical hypothesis testing is to fix, and thereby control, the Type I error (false positive) rate across samples of any size. Multiple comparisons inflate the global (family-wise) Type I error rate and the traditional solution to maintaining control of the error rate is to increase the local (comparison-wise) Type II error (false negative) rates. However, in the analysis of human brain imaging data, the number of comparisons is so large that this solution breaks down: the local Type II error rate ends up being so large that scientifically meaningful analysis is precluded. Here we propose a novel solution to this problem: allow the Type I error rate to converge to zero along with the Type II error rate. It works because when the Type I error rate per comparison is very small, the accumulation (or global) Type I error rate is also small. This solution is achieved by employing the Likelihood paradigm, which uses likelihood ratios to measure the strength of evidence on a voxel-by-voxel basis. In this paper, we provide theoretical and empirical justification for a likelihood approach to the analysis of human brain imaging data. In addition, we present extensive simulations that show the likelihood approach is viable, leading to ‘cleaner’ looking brain maps and operationally superiority (lower average error rate). Finally, we include a case study on cognitive control related activation in the prefrontal cortex of the human brain. PMID:26272730

Human error and the search for blame

NASA Technical Reports Server (NTRS)

Denning, Peter J.

1989-01-01

Human error is a frequent topic in discussions about risks in using computer systems. A rational analysis of human error leads through the consideration of mistakes to standards that designers use to avoid mistakes that lead to known breakdowns. The irrational side, however, is more interesting. It conditions people to think that breakdowns are inherently wrong and that there is ultimately someone who is responsible. This leads to a search for someone to blame which diverts attention from: learning from the mistakes; seeing the limitations of current engineering methodology; and improving the discourse of design.

Why do adult dogs (Canis familiaris) commit the A-not-B search error?

PubMed

Sümegi, Zsófia; Kis, Anna; Miklósi, Ádám; Topál, József

2014-02-01

It has been recently reported that adult domestic dogs, like human infants, tend to commit perseverative search errors; that is, they select the previously rewarded empty location in Piagetian A-not-B search task because of the experimenter's ostensive communicative cues. There is, however, an ongoing debate over whether these findings reveal that dogs can use the human ostensive referential communication as a source of information or the phenomenon can be accounted for by "more simple" explanations like insufficient attention and learning based on local enhancement. In 2 experiments the authors systematically manipulated the type of human cueing (communicative or noncommunicative) adjacent to the A hiding place during both the A and B trials. Results highlight 3 important aspects of the dogs' A-not-B error: (a) search errors are influenced to a certain extent by dogs' motivation to retrieve the toy object; (b) human communicative and noncommunicative signals have different error-inducing effects; and (3) communicative signals presented at the A hiding place during the B trials but not during the A trials play a crucial role in inducing the A-not-B error and it can be induced even without demonstrating repeated hiding events at location A. These findings further confirm the notion that perseverative search error, at least partially, reflects a "ready-to-obey" attitude in the dog rather than insufficient attention and/or working memory.

Common medial frontal mechanisms of adaptive control in humans and rodents

PubMed Central

Frank, Michael J.; Laubach, Mark

2013-01-01

In this report, we describe how common brain networks within the medial frontal cortex facilitate adaptive behavioral control in rodents and humans. We demonstrate that low frequency oscillations below 12 Hz are dramatically modulated after errors in humans over mid-frontal cortex and in rats within prelimbic and anterior cingulate regions of medial frontal cortex. These oscillations were phase-locked between medial frontal cortex and motor areas in both rats and humans. In rats, single neurons that encoded prior behavioral outcomes were phase-coherent with low-frequency field oscillations particularly after errors. Inactivating medial frontal regions in rats led to impaired behavioral adjustments after errors, eliminated the differential expression of low frequency oscillations after errors, and increased low-frequency spike-field coupling within motor cortex. Our results describe a novel mechanism for behavioral adaptation via low-frequency oscillations and elucidate how medial frontal networks synchronize brain activity to guide performance. PMID:24141310

#2 - An Empirical Assessment of Exposure Measurement Error ...

EPA Pesticide Factsheets

Background• Differing degrees of exposure error acrosspollutants• Previous focus on quantifying and accounting forexposure error in single-pollutant models• Examine exposure errors for multiple pollutantsand provide insights on the potential for bias andattenuation of effect estimates in single and bipollutantepidemiological models The National Exposure Research Laboratory (NERL) Human Exposure and Atmospheric Sciences Division (HEASD) conducts research in support of EPA mission to protect human health and the environment. HEASD research program supports Goal 1 (Clean Air) and Goal 4 (Healthy People) of EPA strategic plan. More specifically, our division conducts research to characterize the movement of pollutants from the source to contact with humans. Our multidisciplinary research program produces Methods, Measurements, and Models to identify relationships between and characterize processes that link source emissions, environmental concentrations, human exposures, and target-tissue dose. The impact of these tools is improved regulatory programs and policies for EPA.

Cutting the Cord: Discrimination and Command Responsibility in Autonomous Lethal Weapons

DTIC Science & Technology

2014-02-13

machine responses to identical stimuli, and it was the job of a third party human “witness” to determine which participant was man and which was...machines may be error free, but there are potential benefits to be gained through autonomy if machines can meet or exceed human performance in...lieu of human operators and reap the benefits that autonomy provides. Human and Machine Error It would be foolish to assert that either humans

Human error identification for laparoscopic surgery: Development of a motion economy perspective.

PubMed

Al-Hakim, Latif; Sevdalis, Nick; Maiping, Tanaphon; Watanachote, Damrongpan; Sengupta, Shomik; Dissaranan, Charuspong

2015-09-01

This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Managing human error in aviation.

PubMed

Helmreich, R L

1997-05-01

Crew resource management (CRM) programs were developed to address team and leadership aspects of piloting modern airplanes. The goal is to reduce errors through team work. Human factors research and social, cognitive, and organizational psychology are used to develop programs tailored for individual airlines. Flight crews study accident case histories, group dynamics, and human error. Simulators provide pilots with the opportunity to solve complex flight problems. CRM in the simulator is called line-oriented flight training (LOFT). In automated cockpits CRM promotes the idea of automation as a crew member. Cultural aspects of aviation include professional, business, and national culture. The aviation CRM model has been adapted for training surgeons and operating room staff in human factors.

Empirical Analysis of Systematic Communication Errors.

DTIC Science & Technology

1981-09-01

human o~ . .... 8 components in communication systems. (Systematic errors were defined to be those that occur regularly in human communication links...phase of the human communication process and focuses on the linkage between a specific piece of information (and the receiver) and the transmission...communication flow. (2) Exchange. Exchange is the next phase in human communication and entails a concerted effort on the part of the sender and receiver to share

HRA Aerospace Challenges

NASA Technical Reports Server (NTRS)

DeMott, Diana

2013-01-01

Compared to equipment designed to perform the same function over and over, humans are just not as reliable. Computers and machines perform the same action in the same way repeatedly getting the same result, unless equipment fails or a human interferes. Humans who are supposed to perform the same actions repeatedly often perform them incorrectly due to a variety of issues including: stress, fatigue, illness, lack of training, distraction, acting at the wrong time, not acting when they should, not following procedures, misinterpreting information or inattention to detail. Why not use robots and automatic controls exclusively if human error is so common? In an emergency or off normal situation that the computer, robotic element, or automatic control system is not designed to respond to, the result is failure unless a human can intervene. The human in the loop may be more likely to cause an error, but is also more likely to catch the error and correct it. When it comes to unexpected situations, or performing multiple tasks outside the defined mission parameters, humans are the only viable alternative. Human Reliability Assessments (HRA) identifies ways to improve human performance and reliability and can lead to improvements in systems designed to interact with humans. Understanding the context of the situation that can lead to human errors, which include taking the wrong action, no action or making bad decisions provides additional information to mitigate risks. With improved human reliability comes reduced risk for the overall operation or project.

Identifying Human Factors Issues in Aircraft Maintenance Operations

NASA Technical Reports Server (NTRS)

Veinott, Elizabeth S.; Kanki, Barbara G.; Shafto, Michael G. (Technical Monitor)

1995-01-01

Maintenance operations incidents submitted to the Aviation Safety Reporting System (ASRS) between 1986-1992 were systematically analyzed in order to identify issues relevant to human factors and crew coordination. This exploratory analysis involved 95 ASRS reports which represented a wide range of maintenance incidents. The reports were coded and analyzed according to the type of error (e.g, wrong part, procedural error, non-procedural error), contributing factors (e.g., individual, within-team, cross-team, procedure, tools), result of the error (e.g., aircraft damage or not) as well as the operational impact (e.g., aircraft flown to destination, air return, delay at gate). The main findings indicate that procedural errors were most common (48.4%) and that individual and team actions contributed to the errors in more than 50% of the cases. As for operational results, most errors were either corrected after landing at the destination (51.6%) or required the flight crew to stop enroute (29.5%). Interactions among these variables are also discussed. This analysis is a first step toward developing a taxonomy of crew coordination problems in maintenance. By understanding what variables are important and how they are interrelated, we may develop intervention strategies that are better tailored to the human factor issues involved.

Managing Errors to Reduce Accidents in High Consequence Networked Information Systems

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ganter, J.H.

1999-02-01

Computers have always helped to amplify and propagate errors made by people. The emergence of Networked Information Systems (NISs), which allow people and systems to quickly interact worldwide, has made understanding and minimizing human error more critical. This paper applies concepts from system safety to analyze how hazards (from hackers to power disruptions) penetrate NIS defenses (e.g., firewalls and operating systems) to cause accidents. Such events usually result from both active, easily identified failures and more subtle latent conditions that have resided in the system for long periods. Both active failures and latent conditions result from human errors. We classifymore » these into several types (slips, lapses, mistakes, etc.) and provide NIS examples of how they occur. Next we examine error minimization throughout the NIS lifecycle, from design through operation to reengineering. At each stage, steps can be taken to minimize the occurrence and effects of human errors. These include defensive design philosophies, architectural patterns to guide developers, and collaborative design that incorporates operational experiences and surprises into design efforts. We conclude by looking at three aspects of NISs that will cause continuing challenges in error and accident management: immaturity of the industry, limited risk perception, and resource tradeoffs.« less

Investigating mode errors on automated flight decks: illustrating the problem-driven, cumulative, and interdisciplinary nature of human factors research.

PubMed

Sarter, Nadine

2008-06-01

The goal of this article is to illustrate the problem-driven, cumulative, and highly interdisciplinary nature of human factors research by providing a brief overview of the work on mode errors on modern flight decks over the past two decades. Mode errors on modem flight decks were first reported in the late 1980s. Poor feedback, inadequate mental models of the automation, and the high degree of coupling and complexity of flight deck systems were identified as main contributors to these breakdowns in human-automation interaction. Various improvements of design, training, and procedures were proposed to address these issues. The author describes when and why the problem of mode errors surfaced, summarizes complementary research activities that helped identify and understand the contributing factors to mode errors, and describes some countermeasures that have been developed in recent years. This brief review illustrates how one particular human factors problem in the aviation domain enabled various disciplines and methodological approaches to contribute to a better understanding of, as well as provide better support for, effective human-automation coordination. Converging operations and interdisciplinary collaboration over an extended period of time are hallmarks of successful human factors research. The reported body of research can serve as a model for future research and as a teaching tool for students in this field of work.

The Swiss cheese model of adverse event occurrence--Closing the holes.

PubMed

Stein, James E; Heiss, Kurt

2015-12-01

Traditional surgical attitude regarding error and complications has focused on individual failings. Human factors research has brought new and significant insights into the occurrence of error in healthcare, helping us identify systemic problems that injure patients while enhancing individual accountability and teamwork. This article introduces human factors science and its applicability to teamwork, surgical culture, medical error, and individual accountability. Copyright © 2015 Elsevier Inc. All rights reserved.

Behind Human Error: Cognitive Systems, Computers and Hindsight

DTIC Science & Technology

1994-12-01

evaluations • Organize and/or conduct workshops and conferences CSERIAC is a Department of Defense Information Analysis Cen- ter sponsored by the Defense...Process 185 Neutral Observer Criteria 191 Error Analysis as Causal Judgment 193 Error as Information 195 A Fundamental Surprise 195 What is Human...Kahnemann, 1974), and in risk analysis (Dougherty and Fragola, 1990). The discussions have continued in a wide variety of forums, includ- ing the

Monte Carlo simulation of expert judgments on human errors in chemical analysis--a case study of ICP-MS.

PubMed

Kuselman, Ilya; Pennecchi, Francesca; Epstein, Malka; Fajgelj, Ales; Ellison, Stephen L R

2014-12-01

Monte Carlo simulation of expert judgments on human errors in a chemical analysis was used for determination of distributions of the error quantification scores (scores of likelihood and severity, and scores of effectiveness of a laboratory quality system in prevention of the errors). The simulation was based on modeling of an expert behavior: confident, reasonably doubting and irresolute expert judgments were taken into account by means of different probability mass functions (pmfs). As a case study, 36 scenarios of human errors which may occur in elemental analysis of geological samples by ICP-MS were examined. Characteristics of the score distributions for three pmfs of an expert behavior were compared. Variability of the scores, as standard deviation of the simulated score values from the distribution mean, was used for assessment of the score robustness. A range of the score values, calculated directly from elicited data and simulated by a Monte Carlo method for different pmfs, was also discussed from the robustness point of view. It was shown that robustness of the scores, obtained in the case study, can be assessed as satisfactory for the quality risk management and improvement of a laboratory quality system against human errors. Copyright © 2014 Elsevier B.V. All rights reserved.

Human-computer interaction in multitask situations

NASA Technical Reports Server (NTRS)

Rouse, W. B.

1977-01-01

Human-computer interaction in multitask decisionmaking situations is considered, and it is proposed that humans and computers have overlapping responsibilities. Queueing theory is employed to model this dynamic approach to the allocation of responsibility between human and computer. Results of simulation experiments are used to illustrate the effects of several system variables including number of tasks, mean time between arrivals of action-evoking events, human-computer speed mismatch, probability of computer error, probability of human error, and the level of feedback between human and computer. Current experimental efforts are discussed and the practical issues involved in designing human-computer systems for multitask situations are considered.

Combining task analysis and fault tree analysis for accident and incident analysis: a case study from Bulgaria.

PubMed

Doytchev, Doytchin E; Szwillus, Gerd

2009-11-01

Understanding the reasons for incident and accident occurrence is important for an organization's safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose an analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). The former method identifies the root causes of an accident/incident, while the latter analyses the way people perform the tasks in their work environment and how they interact with machines or colleagues. These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the insight into the error modes of an operator's behaviour. HEIST shows the external error modes that caused the human error and the factors that prompted the human to err. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident - the flooding of the plant's basement - was analysed by combining the afore-mentioned methods. The case study shows that Task Analysis in combination with other methods can be applied successfully to human error analysis, revealing details about erroneous actions in a realistic situation.

Object permanence in adult common marmosets (Callithrix jacchus): not everything is an "A-not-B" error that seems to be one.

PubMed

Kis, Anna; Gácsi, Márta; Range, Friederike; Virányi, Zsófia

2012-01-01

In this paper, we describe a behaviour pattern similar to the "A-not-B" error found in human infants and young apes in a monkey species, the common marmosets (Callithrix jacchus). In contrast to the classical explanation, recently it has been suggested that the "A-not-B" error committed by human infants is at least partially due to misinterpretation of the hider's ostensively communicated object hiding actions as potential 'teaching' demonstrations during the A trials. We tested whether this so-called Natural Pedagogy hypothesis would account for the A-not-B error that marmosets commit in a standard object permanence task, but found no support for the hypothesis in this species. Alternatively, we present evidence that lower level mechanisms, such as attention and motivation, play an important role in committing the "A-not-B" error in marmosets. We argue that these simple mechanisms might contribute to the effect of undeveloped object representational skills in other species including young non-human primates that commit the A-not-B error.

Updating expected action outcome in the medial frontal cortex involves an evaluation of error type.

PubMed

Maier, Martin E; Steinhauser, Marco

2013-10-02

Forming expectations about the outcome of an action is an important prerequisite for action control and reinforcement learning in the human brain. The medial frontal cortex (MFC) has been shown to play an important role in the representation of outcome expectations, particularly when an update of expected outcome becomes necessary because an error is detected. However, error detection alone is not always sufficient to compute expected outcome because errors can occur in various ways and different types of errors may be associated with different outcomes. In the present study, we therefore investigate whether updating expected outcome in the human MFC is based on an evaluation of error type. Our approach was to consider an electrophysiological correlate of MFC activity on errors, the error-related negativity (Ne/ERN), in a task in which two types of errors could occur. Because the two error types were associated with different amounts of monetary loss, updating expected outcomes on error trials required an evaluation of error type. Our data revealed a pattern of Ne/ERN amplitudes that closely mirrored the amount of monetary loss associated with each error type, suggesting that outcome expectations are updated based on an evaluation of error type. We propose that this is achieved by a proactive evaluation process that anticipates error types by continuously monitoring error sources or by dynamically representing possible response-outcome relations.

Accounting for measurement error in human life history trade-offs using structural equation modeling.

PubMed

Helle, Samuli

2018-03-01

Revealing causal effects from correlative data is very challenging and a contemporary problem in human life history research owing to the lack of experimental approach. Problems with causal inference arising from measurement error in independent variables, whether related either to inaccurate measurement technique or validity of measurements, seem not well-known in this field. The aim of this study is to show how structural equation modeling (SEM) with latent variables can be applied to account for measurement error in independent variables when the researcher has recorded several indicators of a hypothesized latent construct. As a simple example of this approach, measurement error in lifetime allocation of resources to reproduction in Finnish preindustrial women is modelled in the context of the survival cost of reproduction. In humans, lifetime energetic resources allocated in reproduction are almost impossible to quantify with precision and, thus, typically used measures of lifetime reproductive effort (e.g., lifetime reproductive success and parity) are likely to be plagued by measurement error. These results are contrasted with those obtained from a traditional regression approach where the single best proxy of lifetime reproductive effort available in the data is used for inference. As expected, the inability to account for measurement error in women's lifetime reproductive effort resulted in the underestimation of its underlying effect size on post-reproductive survival. This article emphasizes the advantages that the SEM framework can provide in handling measurement error via multiple-indicator latent variables in human life history studies. © 2017 Wiley Periodicals, Inc.

Reliability of drivers in urban intersections.

PubMed

Gstalter, Herbert; Fastenmeier, Wolfgang

2010-01-01

The concept of human reliability has been widely used in industrial settings by human factors experts to optimise the person-task fit. Reliability is estimated by the probability that a task will successfully be completed by personnel in a given stage of system operation. Human Reliability Analysis (HRA) is a technique used to calculate human error probabilities as the ratio of errors committed to the number of opportunities for that error. To transfer this notion to the measurement of car driver reliability the following components are necessary: a taxonomy of driving tasks, a definition of correct behaviour in each of these tasks, a list of errors as deviations from the correct actions and an adequate observation method to register errors and opportunities for these errors. Use of the SAFE-task analysis procedure recently made it possible to derive driver errors directly from the normative analysis of behavioural requirements. Driver reliability estimates could be used to compare groups of tasks (e.g. different types of intersections with their respective regulations) as well as groups of drivers' or individual drivers' aptitudes. This approach was tested in a field study with 62 drivers of different age groups. The subjects drove an instrumented car and had to complete an urban test route, the main features of which were 18 intersections representing six different driving tasks. The subjects were accompanied by two trained observers who recorded driver errors using standardized observation sheets. Results indicate that error indices often vary between both the age group of drivers and the type of driving task. The highest error indices occurred in the non-signalised intersection tasks and the roundabout, which exactly equals the corresponding ratings of task complexity from the SAFE analysis. A comparison of age groups clearly shows the disadvantage of older drivers, whose error indices in nearly all tasks are significantly higher than those of the other groups. The vast majority of these errors could be explained by high task load in the intersections, as they represent difficult tasks. The discussion shows how reliability estimates can be used in a constructive way to propose changes in car design, intersection layout and regulation as well as driver training.

Safety coaches in radiology: decreasing human error and minimizing patient harm.

PubMed

Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

2010-09-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

Error-associated behaviors and error rates for robotic geology

NASA Technical Reports Server (NTRS)

Anderson, Robert C.; Thomas, Geb; Wagner, Jacob; Glasgow, Justin

2004-01-01

This study explores human error as a function of the decision-making process. One of many models for human decision-making is Rasmussen's decision ladder [9]. The decision ladder identifies the multiple tasks and states of knowledge involved in decision-making. The tasks and states of knowledge can be classified by the level of cognitive effort required to make the decision, leading to the skill, rule, and knowledge taxonomy (Rasmussen, 1987). Skill based decisions require the least cognitive effort and knowledge based decisions require the greatest cognitive effort. Errors can occur at any of the cognitive levels.

Procedural error monitoring and smart checklists

NASA Technical Reports Server (NTRS)

Palmer, Everett

1990-01-01

Human beings make and usually detect errors routinely. The same mental processes that allow humans to cope with novel problems can also lead to error. Bill Rouse has argued that errors are not inherently bad but their consequences may be. He proposes the development of error-tolerant systems that detect errors and take steps to prevent the consequences of the error from occurring. Research should be done on self and automatic detection of random and unanticipated errors. For self detection, displays should be developed that make the consequences of errors immediately apparent. For example, electronic map displays graphically show the consequences of horizontal flight plan entry errors. Vertical profile displays should be developed to make apparent vertical flight planning errors. Other concepts such as energy circles could also help the crew detect gross flight planning errors. For automatic detection, systems should be developed that can track pilot activity, infer pilot intent and inform the crew of potential errors before their consequences are realized. Systems that perform a reasonableness check on flight plan modifications by checking route length and magnitude of course changes are simple examples. Another example would be a system that checked the aircraft's planned altitude against a data base of world terrain elevations. Information is given in viewgraph form.

A circadian rhythm in skill-based errors in aviation maintenance.

PubMed

Hobbs, Alan; Williamson, Ann; Van Dongen, Hans P A

2010-07-01

In workplaces where activity continues around the clock, human error has been observed to exhibit a circadian rhythm, with a characteristic peak in the early hours of the morning. Errors are commonly distinguished by the nature of the underlying cognitive failure, particularly the level of intentionality involved in the erroneous action. The Skill-Rule-Knowledge (SRK) framework of Rasmussen is used widely in the study of industrial errors and accidents. The SRK framework describes three fundamental types of error, according to whether behavior is under the control of practiced sensori-motor skill routines with minimal conscious awareness; is guided by implicit or explicit rules or expertise; or where the planning of actions requires the conscious application of domain knowledge. Up to now, examinations of circadian patterns of industrial errors have not distinguished between different types of error. Consequently, it is not clear whether all types of error exhibit the same circadian rhythm. A survey was distributed to aircraft maintenance personnel in Australia. Personnel were invited to anonymously report a safety incident and were prompted to describe, in detail, the human involvement (if any) that contributed to it. A total of 402 airline maintenance personnel reported an incident, providing 369 descriptions of human error in which the time of the incident was reported and sufficient detail was available to analyze the error. Errors were categorized using a modified version of the SRK framework, in which errors are categorized as skill-based, rule-based, or knowledge-based, or as procedure violations. An independent check confirmed that the SRK framework had been applied with sufficient consistency and reliability. Skill-based errors were the most common form of error, followed by procedure violations, rule-based errors, and knowledge-based errors. The frequency of errors was adjusted for the estimated proportion of workers present at work/each hour of the day, and the 24 h pattern of each error type was examined. Skill-based errors exhibited a significant circadian rhythm, being most prevalent in the early hours of the morning. Variation in the frequency of rule-based errors, knowledge-based errors, and procedure violations over the 24 h did not reach statistical significance. The results suggest that during the early hours of the morning, maintenance technicians are at heightened risk of "absent minded" errors involving failures to execute action plans as intended.

Spatial durbin error model for human development index in Province of Central Java.

NASA Astrophysics Data System (ADS)

Septiawan, A. R.; Handajani, S. S.; Martini, T. S.

2018-05-01

The Human Development Index (HDI) is an indicator used to measure success in building the quality of human life, explaining how people access development outcomes when earning income, health and education. Every year HDI in Central Java has improved to a better direction. In 2016, HDI in Central Java was 69.98 %, an increase of 0.49 % over the previous year. The objective of this study was to apply the spatial Durbin error model using angle weights queen contiguity to measure HDI in Central Java Province. Spatial Durbin error model is used because the model overcomes the spatial effect of errors and the effects of spatial depedency on the independent variable. Factors there use is life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity. Based on the result of research, we get spatial Durbin error model for HDI in Central Java with influencing factors are life expectancy, mean years of schooling, expected years of schooling, and purchasing power parity.

Hierarchical learning induces two simultaneous, but separable, prediction errors in human basal ganglia.

PubMed

Diuk, Carlos; Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew; Niv, Yael

2013-03-27

Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously.

Mental representation of symbols as revealed by vocabulary errors in two bonobos (Pan paniscus).

PubMed

Lyn, Heidi

2007-10-01

Error analysis has been used in humans to detect implicit representations and categories in language use. The present study utilizes the same technique to report on mental representations and categories in symbol use from two bonobos (Pan paniscus). These bonobos have been shown in published reports to comprehend English at the level of a two-and-a-half year old child and to use a keyboard with over 200 visuographic symbols (lexigrams). In this study, vocabulary test errors from over 10 years of data revealed auditory, visual, and spatio-temporal generalizations (errors were more likely items that looked like sounded like, or were frequently associated with the sample item in space or in time), as well as hierarchical and conceptual categorizations. These error data, like those of humans, are a result of spontaneous responding rather than specific training and do not solely depend upon the sample mode (e.g. auditory similarity errors are not universally more frequent with an English sample, nor were visual similarity errors universally more frequent with a photograph sample). However, unlike humans, these bonobos do not make errors based on syntactical confusions (e.g. confusing semantically unrelated nouns), suggesting that they may not separate syntactical and semantic information. These data suggest that apes spontaneously create a complex, hierarchical, web of representations when exposed to a symbol system.

78 FR 11237 - Public Hearing

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-15

... management of human error in its operations and system safety programs, and the status of PTC implementation... UP's safety management policies and programs associated with human error, operational accident and... Chairman of the Board of Inquiry 2. Introduction of the Board of Inquiry and Technical Panel 3...

Intravenous Chemotherapy Compounding Errors in a Follow-Up Pan-Canadian Observational Study.

PubMed

Gilbert, Rachel E; Kozak, Melissa C; Dobish, Roxanne B; Bourrier, Venetia C; Koke, Paul M; Kukreti, Vishal; Logan, Heather A; Easty, Anthony C; Trbovich, Patricia L

2018-05-01

Intravenous (IV) compounding safety has garnered recent attention as a result of high-profile incidents, awareness efforts from the safety community, and increasingly stringent practice standards. New research with more-sensitive error detection techniques continues to reinforce that error rates with manual IV compounding are unacceptably high. In 2014, our team published an observational study that described three types of previously unrecognized and potentially catastrophic latent chemotherapy preparation errors in Canadian oncology pharmacies that would otherwise be undetectable. We expand on this research and explore whether additional potential human failures are yet to be addressed by practice standards. Field observations were conducted in four cancer center pharmacies in four Canadian provinces from January 2013 to February 2015. Human factors specialists observed and interviewed pharmacy managers, oncology pharmacists, pharmacy technicians, and pharmacy assistants as they carried out their work. Emphasis was on latent errors (potential human failures) that could lead to outcomes such as wrong drug, dose, or diluent. Given the relatively short observational period, no active failures or actual errors were observed. However, 11 latent errors in chemotherapy compounding were identified. In terms of severity, all 11 errors create the potential for a patient to receive the wrong drug or dose, which in the context of cancer care, could lead to death or permanent loss of function. Three of the 11 practices were observed in our previous study, but eight were new. Applicable Canadian and international standards and guidelines do not explicitly address many of the potentially error-prone practices observed. We observed a significant degree of risk for error in manual mixing practice. These latent errors may exist in other regions where manual compounding of IV chemotherapy takes place. Continued efforts to advance standards, guidelines, technological innovation, and chemical quality testing are needed.

Spacecraft and propulsion technician error

NASA Astrophysics Data System (ADS)

Schultz, Daniel Clyde

Commercial aviation and commercial space similarly launch, fly, and land passenger vehicles. Unlike aviation, the U.S. government has not established maintenance policies for commercial space. This study conducted a mixed methods review of 610 U.S. space launches from 1984 through 2011, which included 31 failures. An analysis of the failure causal factors showed that human error accounted for 76% of those failures, which included workmanship error accounting for 29% of the failures. With the imminent future of commercial space travel, the increased potential for the loss of human life demands that changes be made to the standardized procedures, training, and certification to reduce human error and failure rates. Several recommendations were made by this study to the FAA's Office of Commercial Space Transportation, space launch vehicle operators, and maintenance technician schools in an effort to increase the safety of the space transportation passengers.

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 5 2012-10-01 2012-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 5 2014-10-01 2014-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 5 2010-10-01 2010-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 5 2013-10-01 2013-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 1005.23 - Harmless error.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 5 2011-10-01 2011-10-01 false Harmless error. 1005.23 Section 1005.23 Public Health OFFICE OF INSPECTOR GENERAL-HEALTH CARE, DEPARTMENT OF HEALTH AND HUMAN SERVICES OIG AUTHORITIES APPEALS OF EXCLUSIONS, CIVIL MONEY PENALTIES AND ASSESSMENTS § 1005.23 Harmless error. No error in either...

42 CFR 3.552 - Harmless error.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 1 2010-10-01 2010-10-01 false Harmless error. 3.552 Section 3.552 Public Health PUBLIC HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL PROVISIONS PATIENT SAFETY ORGANIZATIONS AND PATIENT SAFETY WORK PRODUCT Enforcement Program § 3.552 Harmless error. No error in either the...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 45 Public Welfare 1 2013-10-01 2013-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 45 Public Welfare 1 2014-10-01 2014-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 1 2011-10-01 2011-10-01 false Error Rate Report. 98.100 Section 98.100 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.100 Error Rate Report. (a) Applicability—The requirements of this subpart...

Defense Mapping Agency (DMA) Raster-to-Vector Analysis

DTIC Science & Technology

1984-11-30

model) to pinpoint critical deficiencies and understand trade-offs between alternative solutions. This may be exemplified by the allocation of human ...process, prone to errors (i.e., human operator eye/motor control limitations), and its time consuming nature (as a function of data density). It should...achieved through the facilities of coinputer interactive graphics. Each error or anomaly is individually identified by a human operator and corrected

How we learn to make decisions: rapid propagation of reinforcement learning prediction errors in humans.

PubMed

Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C

2014-03-01

Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward prediction errors and the changes in amplitude of these prediction errors at the time of choice presentation and reward delivery. Our results provide further support that the computations that underlie human learning and decision-making follow reinforcement learning principles.

Causal Evidence from Humans for the Role of Mediodorsal Nucleus of the Thalamus in Working Memory.

PubMed

Peräkylä, Jari; Sun, Lihua; Lehtimäki, Kai; Peltola, Jukka; Öhman, Juha; Möttönen, Timo; Ogawa, Keith H; Hartikainen, Kaisa M

2017-12-01

The mediodorsal nucleus of the thalamus (MD), with its extensive connections to the lateral pFC, has been implicated in human working memory and executive functions. However, this understanding is based solely on indirect evidence from human lesion and imaging studies and animal studies. Direct, causal evidence from humans is missing. To obtain direct evidence for MD's role in humans, we studied patients treated with deep brain stimulation (DBS) for refractory epilepsy. This treatment is thought to prevent the generalization of a seizure by disrupting the functioning of the patient's anterior nuclei of the thalamus (ANT) with high-frequency electric stimulation. This structure is located superior and anterior to MD, and when the DBS lead is implanted in ANT, tip contacts of the lead typically penetrate through ANT into the adjoining MD. To study the role of MD in human executive functions and working memory, we periodically disrupted and recovered MD's function with high-frequency electric stimulation using DBS contacts reaching MD while participants performed a cognitive task engaging several aspects of executive functions. We hypothesized that the efficacy of executive functions, specifically working memory, is impaired when the functioning of MD is perturbed by high-frequency stimulation. Eight participants treated with ANT-DBS for refractory epilepsy performed a computer-based test of executive functions while DBS was repeatedly switched ON and OFF at MD and at the control location (ANT). In comparison to stimulation of the control location, when MD was stimulated, participants committed 2.26 times more errors in general (total errors; OR = 2.26, 95% CI [1.69, 3.01]) and 2.86 times more working memory-related errors specifically (incorrect button presses; OR = 2.88, CI [1.95, 4.24]). Similarly, participants committed 1.81 more errors in general ( OR = 1.81, CI [1.45, 2.24]) and 2.08 times more working memory-related errors ( OR = 2.08, CI [1.57, 2.75]) in comparison to no stimulation condition. "Total errors" is a composite score consisting of basic error types and was mostly driven by working memory-related errors. The facts that MD and a control location, ANT, are only few millimeters away from each other and that their stimulation produces very different results highlight the location-specific effect of DBS rather than regionally unspecific general effect. In conclusion, disrupting and recovering MD's function with high-frequency electric stimulation modulated participants' online working memory performance providing causal, in vivo evidence from humans for the role of MD in human working memory.

A Method for the Study of Human Factors in Aircraft Operations

NASA Technical Reports Server (NTRS)

Barnhart, W.; Billings, C.; Cooper, G.; Gilstrap, R.; Lauber, J.; Orlady, H.; Puskas, B.; Stephens, W.

1975-01-01

A method for the study of human factors in the aviation environment is described. A conceptual framework is provided within which pilot and other human errors in aircraft operations may be studied with the intent of finding out how, and why, they occurred. An information processing model of human behavior serves as the basis for the acquisition and interpretation of information relating to occurrences which involve human error. A systematic method of collecting such data is presented and discussed. The classification of the data is outlined.

An interactive framework for acquiring vision models of 3-D objects from 2-D images.

PubMed

Motai, Yuichi; Kak, Avinash

2004-02-01

This paper presents a human-computer interaction (HCI) framework for building vision models of three-dimensional (3-D) objects from their two-dimensional (2-D) images. Our framework is based on two guiding principles of HCI: 1) provide the human with as much visual assistance as possible to help the human make a correct input; and 2) verify each input provided by the human for its consistency with the inputs previously provided. For example, when stereo correspondence information is elicited from a human, his/her job is facilitated by superimposing epipolar lines on the images. Although that reduces the possibility of error in the human marked correspondences, such errors are not entirely eliminated because there can be multiple candidate points close together for complex objects. For another example, when pose-to-pose correspondence is sought from a human, his/her job is made easier by allowing the human to rotate the partial model constructed in the previous pose in relation to the partial model for the current pose. While this facility reduces the incidence of human-supplied pose-to-pose correspondence errors, such errors cannot be eliminated entirely because of confusion created when multiple candidate features exist close together. Each input provided by the human is therefore checked against the previous inputs by invoking situation-specific constraints. Different types of constraints (and different human-computer interaction protocols) are needed for the extraction of polygonal features and for the extraction of curved features. We will show results on both polygonal objects and object containing curved features.

New methodology to reconstruct in 2-D the cuspal enamel of modern human lower molars.

PubMed

Modesto-Mata, Mario; García-Campos, Cecilia; Martín-Francés, Laura; Martínez de Pinillos, Marina; García-González, Rebeca; Quintino, Yuliet; Canals, Antoni; Lozano, Marina; Dean, M Christopher; Martinón-Torres, María; Bermúdez de Castro, José María

2017-08-01

In the last years different methodologies have been developed to reconstruct worn teeth. In this article, we propose a new 2-D methodology to reconstruct the worn enamel of lower molars. Our main goals are to reconstruct molars with a high level of accuracy when measuring relevant histological variables and to validate the methodology calculating the errors associated with the measurements. This methodology is based on polynomial regression equations, and has been validated using two different dental variables: cuspal enamel thickness and crown height of the protoconid. In order to perform the validation process, simulated worn modern human molars were employed. The associated errors of the measurements were also estimated applying methodologies previously proposed by other authors. The mean percentage error estimated in reconstructed molars for these two variables in comparison with their own real values is -2.17% for the cuspal enamel thickness of the protoconid and -3.18% for the crown height of the protoconid. This error significantly improves the results of other methodologies, both in the interobserver error and in the accuracy of the measurements. The new methodology based on polynomial regressions can be confidently applied to the reconstruction of cuspal enamel of lower molars, as it improves the accuracy of the measurements and reduces the interobserver error. The present study shows that it is important to validate all methodologies in order to know the associated errors. This new methodology can be easily exportable to other modern human populations, the human fossil record and forensic sciences. © 2017 Wiley Periodicals, Inc.

Safety and Performance Analysis of the Non-Radar Oceanic/Remote Airspace In-Trail Procedure

NASA Technical Reports Server (NTRS)

Carreno, Victor A.; Munoz, Cesar A.

2007-01-01

This document presents a safety and performance analysis of the nominal case for the In-Trail Procedure (ITP) in a non-radar oceanic/remote airspace. The analysis estimates the risk of collision between the aircraft performing the ITP and a reference aircraft. The risk of collision is only estimated for the ITP maneuver and it is based on nominal operating conditions. The analysis does not consider human error, communication error conditions, or the normal risk of flight present in current operations. The hazards associated with human error and communication errors are evaluated in an Operational Hazards Analysis presented elsewhere.

A cognitive taxonomy of medical errors.

PubMed

Zhang, Jiajie; Patel, Vimla L; Johnson, Todd R; Shortliffe, Edward H

2004-06-01

Propose a cognitive taxonomy of medical errors at the level of individuals and their interactions with technology. Use cognitive theories of human error and human action to develop the theoretical foundations of the taxonomy, develop the structure of the taxonomy, populate the taxonomy with examples of medical error cases, identify cognitive mechanisms for each category of medical error under the taxonomy, and apply the taxonomy to practical problems. Four criteria were used to evaluate the cognitive taxonomy. The taxonomy should be able (1) to categorize major types of errors at the individual level along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to describe how and explain why a specific error occurs, and (4) to generate intervention strategies for each type of error. The proposed cognitive taxonomy largely satisfies the four criteria at a theoretical and conceptual level. Theoretically, the proposed cognitive taxonomy provides a method to systematically categorize medical errors at the individual level along cognitive dimensions, leads to a better understanding of the underlying cognitive mechanisms of medical errors, and provides a framework that can guide future studies on medical errors. Practically, it provides guidelines for the development of cognitive interventions to decrease medical errors and foundation for the development of medical error reporting system that not only categorizes errors but also identifies problems and helps to generate solutions. To validate this model empirically, we will next be performing systematic experimental studies.

Differential sensitivity to human communication in dogs, wolves, and human infants.

PubMed

Topál, József; Gergely, György; Erdohegyi, Agnes; Csibra, Gergely; Miklósi, Adám

2009-09-04

Ten-month-old infants persistently search for a hidden object at its initial hiding place even after observing it being hidden at another location. Recent evidence suggests that communicative cues from the experimenter contribute to the emergence of this perseverative search error. We replicated these results with dogs (Canis familiaris), who also commit more search errors in ostensive-communicative (in 75% of the total trials) than in noncommunicative (39%) or nonsocial (17%) hiding contexts. However, comparative investigations suggest that communicative signals serve different functions for dogs and infants, whereas human-reared wolves (Canis lupus) do not show doglike context-dependent differences of search errors. We propose that shared sensitivity to human communicative signals stems from convergent social evolution of the Homo and the Canis genera.

Metrics for Business Process Models

NASA Astrophysics Data System (ADS)

Mendling, Jan

Up until now, there has been little research on why people introduce errors in real-world business process models. In a more general context, Simon [404] points to the limitations of cognitive capabilities and concludes that humans act rationally only to a certain extent. Concerning modeling errors, this argument would imply that human modelers lose track of the interrelations of large and complex models due to their limited cognitive capabilities and introduce errors that they would not insert in a small model. A recent study by Mendling et al. [275] explores in how far certain complexity metrics of business process models have the potential to serve as error determinants. The authors conclude that complexity indeed appears to have an impact on error probability. Before we can test such a hypothesis in a more general setting, we have to establish an understanding of how we can define determinants that drive error probability and how we can measure them.

Hierarchical Learning Induces Two Simultaneous, But Separable, Prediction Errors in Human Basal Ganglia

PubMed Central

Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew

2013-01-01

Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously. PMID:23536092

Associations between errors and contributing factors in aircraft maintenance

NASA Technical Reports Server (NTRS)

Hobbs, Alan; Williamson, Ann

2003-01-01

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.

Neuroanatomical dissociation for taxonomic and thematic knowledge in the human brain

PubMed Central

Schwartz, Myrna F.; Kimberg, Daniel Y.; Walker, Grant M.; Brecher, Adelyn; Faseyitan, Olufunsho K.; Dell, Gary S.; Mirman, Daniel; Coslett, H. Branch

2011-01-01

It is thought that semantic memory represents taxonomic information differently from thematic information. This study investigated the neural basis for the taxonomic-thematic distinction in a unique way. We gathered picture-naming errors from 86 individuals with poststroke language impairment (aphasia). Error rates were determined separately for taxonomic errors (“pear” in response to apple) and thematic errors (“worm” in response to apple), and their shared variance was regressed out of each measure. With the segmented lesions normalized to a common template, we carried out voxel-based lesion-symptom mapping on each error type separately. We found that taxonomic errors localized to the left anterior temporal lobe and thematic errors localized to the left temporoparietal junction. This is an indication that the contribution of these regions to semantic memory cleaves along taxonomic-thematic lines. Our findings show that a distinction long recognized in the psychological sciences is grounded in the structure and function of the human brain. PMID:21540329

Interspecies scaling and prediction of human clearance: comparison of small- and macro-molecule drugs

PubMed Central

Huh, Yeamin; Smith, David E.; Feng, Meihau Rose

2014-01-01

Human clearance prediction for small- and macro-molecule drugs was evaluated and compared using various scaling methods and statistical analysis.Human clearance is generally well predicted using single or multiple species simple allometry for macro- and small-molecule drugs excreted renally.The prediction error is higher for hepatically eliminated small-molecules using single or multiple species simple allometry scaling, and it appears that the prediction error is mainly associated with drugs with low hepatic extraction ratio (Eh). The error in human clearance prediction for hepatically eliminated small-molecules was reduced using scaling methods with a correction of maximum life span (MLP) or brain weight (BRW).Human clearance of both small- and macro-molecule drugs is well predicted using the monkey liver blood flow method. Predictions using liver blood flow from other species did not work as well, especially for the small-molecule drugs. PMID:21892879

Fifty Years of THERP and Human Reliability Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ronald L. Boring

2012-06-01

In 1962 at a Human Factors Society symposium, Alan Swain presented a paper introducing a Technique for Human Error Rate Prediction (THERP). This was followed in 1963 by a Sandia Laboratories monograph outlining basic human error quantification using THERP and, in 1964, by a special journal edition of Human Factors on quantification of human performance. Throughout the 1960s, Swain and his colleagues focused on collecting human performance data for the Sandia Human Error Rate Bank (SHERB), primarily in connection with supporting the reliability of nuclear weapons assembly in the US. In 1969, Swain met with Jens Rasmussen of Risø Nationalmore » Laboratory and discussed the applicability of THERP to nuclear power applications. By 1975, in WASH-1400, Swain had articulated the use of THERP for nuclear power applications, and the approach was finalized in the watershed publication of the NUREG/CR-1278 in 1983. THERP is now 50 years old, and remains the most well known and most widely used HRA method. In this paper, the author discusses the history of THERP, based on published reports and personal communication and interviews with Swain. The author also outlines the significance of THERP. The foundations of human reliability analysis are found in THERP: human failure events, task analysis, performance shaping factors, human error probabilities, dependence, event trees, recovery, and pre- and post-initiating events were all introduced in THERP. While THERP is not without its detractors, and it is showing signs of its age in the face of newer technological applications, the longevity of THERP is a testament of its tremendous significance. THERP started the field of human reliability analysis. This paper concludes with a discussion of THERP in the context of newer methods, which can be seen as extensions of or departures from Swain’s pioneering work.« less

Error-free replicative bypass of (6–4) photoproducts by DNA polymerase ζ in mouse and human cells

PubMed Central

Yoon, Jung-Hoon; Prakash, Louise; Prakash, Satya

2010-01-01

The ultraviolet (UV)-induced (6–4) pyrimidine–pyrimidone photoproduct [(6–4) PP] confers a large structural distortion in DNA. Here we examine in human cells the roles of translesion synthesis (TLS) DNA polymerases (Pols) in promoting replication through a (6–4) TT photoproduct carried on a duplex plasmid where bidirectional replication initiates from an origin of replication. We show that TLS contributes to a large fraction of lesion bypass and that it is mostly error-free. We find that, whereas Pol η and Pol ι provide alternate pathways for mutagenic TLS, surprisingly, Pol ζ functions independently of these Pols and in a predominantly error-free manner. We verify and extend these observations in mouse cells and conclude that, in human cells, TLS during replication can be markedly error-free even opposite a highly distorting DNA lesion. PMID:20080950

A Framework for Modeling Human-Machine Interactions

NASA Technical Reports Server (NTRS)

Shafto, Michael G.; Rosekind, Mark R. (Technical Monitor)

1996-01-01

Modern automated flight-control systems employ a variety of different behaviors, or modes, for managing the flight. While developments in cockpit automation have resulted in workload reduction and economical advantages, they have also given rise to an ill-defined class of human-machine problems, sometimes referred to as 'automation surprises'. Our interest in applying formal methods for describing human-computer interaction stems from our ongoing research on cockpit automation. In this area of aeronautical human factors, there is much concern about how flight crews interact with automated flight-control systems, so that the likelihood of making errors, in particular mode-errors, is minimized and the consequences of such errors are contained. The goal of the ongoing research on formal methods in this context is: (1) to develop a framework for describing human interaction with control systems; (2) to formally categorize such automation surprises; and (3) to develop tests for identification of these categories early in the specification phase of a new human-machine system.

Inborn Errors of Human JAKs and STATs

PubMed Central

Casanova, Jean-Laurent; Holland, Steven M.; Notarangelo, Luigi D.

2012-01-01

Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying bi-allelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high level of allelic heterogeneity at the human JAK3, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. PMID:22520845

Inborn errors of human JAKs and STATs.

PubMed

Casanova, Jean-Laurent; Holland, Steven M; Notarangelo, Luigi D

2012-04-20

Inborn errors of the genes encoding two of the four human JAKs (JAK3 and TYK2) and three of the six human STATs (STAT1, STAT3, and STAT5B) have been described. We review the disorders arising from mutations in these five genes, highlighting the way in which the molecular and cellular pathogenesis of these conditions has been clarified by the discovery of inborn errors of cytokines, hormones, and their receptors, including those interacting with JAKs and STATs. The phenotypic similarities between mice and humans lacking individual JAK-STAT components suggest that the functions of JAKs and STATs are largely conserved in mammals. However, a wide array of phenotypic differences has emerged between mice and humans carrying biallelic null alleles of JAK3, TYK2, STAT1, or STAT5B. Moreover, the high degree of allelic heterogeneity at the human JAK3, TYK2, STAT1, and STAT3 loci has revealed highly diverse immunological and clinical phenotypes, which had not been anticipated. Copyright © 2012 Elsevier Inc. All rights reserved.

Use of modeling to identify vulnerabilities to human error in laparoscopy.

PubMed

Funk, Kenneth H; Bauer, James D; Doolen, Toni L; Telasha, David; Nicolalde, R Javier; Reeber, Miriam; Yodpijit, Nantakrit; Long, Myra

2010-01-01

This article describes an exercise to investigate the utility of modeling and human factors analysis in understanding surgical processes and their vulnerabilities to medical error. A formal method to identify error vulnerabilities was developed and applied to a test case of Veress needle insertion during closed laparoscopy. A team of 2 surgeons, a medical assistant, and 3 engineers used hierarchical task analysis and Integrated DEFinition language 0 (IDEF0) modeling to create rich models of the processes used in initial port creation. Using terminology from a standardized human performance database, detailed task descriptions were written for 4 tasks executed in the process of inserting the Veress needle. Key terms from the descriptions were used to extract from the database generic errors that could occur. Task descriptions with potential errors were translated back into surgical terminology. Referring to the process models and task descriptions, the team used a modified failure modes and effects analysis (FMEA) to consider each potential error for its probability of occurrence, its consequences if it should occur and be undetected, and its probability of detection. The resulting likely and consequential errors were prioritized for intervention. A literature-based validation study confirmed the significance of the top error vulnerabilities identified using the method. Ongoing work includes design and evaluation of procedures to correct the identified vulnerabilities and improvements to the modeling and vulnerability identification methods. Copyright 2010 AAGL. Published by Elsevier Inc. All rights reserved.

Detection of Error Related Neuronal Responses Recorded by Electrocorticography in Humans during Continuous Movements

PubMed Central

Milekovic, Tomislav; Ball, Tonio; Schulze-Bonhage, Andreas; Aertsen, Ad; Mehring, Carsten

2013-01-01

Background Brain-machine interfaces (BMIs) can translate the neuronal activity underlying a user’s movement intention into movements of an artificial effector. In spite of continuous improvements, errors in movement decoding are still a major problem of current BMI systems. If the difference between the decoded and intended movements becomes noticeable, it may lead to an execution error. Outcome errors, where subjects fail to reach a certain movement goal, are also present during online BMI operation. Detecting such errors can be beneficial for BMI operation: (i) errors can be corrected online after being detected and (ii) adaptive BMI decoding algorithm can be updated to make fewer errors in the future. Methodology/Principal Findings Here, we show that error events can be detected from human electrocorticography (ECoG) during a continuous task with high precision, given a temporal tolerance of 300–400 milliseconds. We quantified the error detection accuracy and showed that, using only a small subset of 2×2 ECoG electrodes, 82% of detection information for outcome error and 74% of detection information for execution error available from all ECoG electrodes could be retained. Conclusions/Significance The error detection method presented here could be used to correct errors made during BMI operation or to adapt a BMI algorithm to make fewer errors in the future. Furthermore, our results indicate that smaller ECoG implant could be used for error detection. Reducing the size of an ECoG electrode implant used for BMI decoding and error detection could significantly reduce the medical risk of implantation. PMID:23383315

Inborn Errors of Fructose Metabolism. What Can We Learn from Them?

PubMed

Tran, Christel

2017-04-03

Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases.

Inborn Errors of Fructose Metabolism. What Can We Learn from Them?

PubMed Central

Tran, Christel

2017-01-01

Fructose is one of the main sweetening agents in the human diet and its ingestion is increasing globally. Dietary sugar has particular effects on those whose capacity to metabolize fructose is limited. If intolerance to carbohydrates is a frequent finding in children, inborn errors of carbohydrate metabolism are rare conditions. Three inborn errors are known in the pathway of fructose metabolism; (1) essential or benign fructosuria due to fructokinase deficiency; (2) hereditary fructose intolerance; and (3) fructose-1,6-bisphosphatase deficiency. In this review the focus is set on the description of the clinical symptoms and biochemical anomalies in the three inborn errors of metabolism. The potential toxic effects of fructose in healthy humans also are discussed. Studies conducted in patients with inborn errors of fructose metabolism helped to understand fructose metabolism and its potential toxicity in healthy human. Influence of fructose on the glycolytic pathway and on purine catabolism is the cause of hypoglycemia, lactic acidosis and hyperuricemia. The discovery that fructose-mediated generation of uric acid may have a causal role in diabetes and obesity provided new understandings into pathogenesis for these frequent diseases. PMID:28368361

Using lean "automation with a human touch" to improve medication safety: a step closer to the "perfect dose".

PubMed

Ching, Joan M; Williams, Barbara L; Idemoto, Lori M; Blackmore, C Craig

2014-08-01

Virginia Mason Medical Center (Seattle) employed the Lean concept of Jidoka (automation with a human touch) to plan for and deploy bar code medication administration (BCMA) to hospitalized patients. Integrating BCMA technology into the nursing work flow with minimal disruption was accomplished using three steps ofJidoka: (1) assigning work to humans and machines on the basis of their differing abilities, (2) adapting machines to the human work flow, and (3) monitoring the human-machine interaction. Effectiveness of BCMA to both reinforce safe administration practices and reduce medication errors was measured using the Collaborative Alliance for Nursing Outcomes (CALNOC) Medication Administration Accuracy Quality Study methodology. Trained nurses observed a total of 16,149 medication doses for 3,617 patients in a three-year period. Following BCMA implementation, the number of safe practice violations decreased from 54.8 violations/100 doses (January 2010-September 2011) to 29.0 violations/100 doses (October 2011-December 2012), resulting in an absolute risk reduction of 25.8 violations/100 doses (95% confidence interval [CI]: 23.7, 27.9, p < .001). The number of medication errors decreased from 5.9 errors/100 doses at baseline to 3.0 errors/100 doses after BCMA implementation (absolute risk reduction: 2.9 errors/100 doses [95% CI: 2.2, 3.6,p < .001]). The number of unsafe administration practices (estimate, -5.481; standard error 1.133; p < .001; 95% CI: -7.702, -3.260) also decreased. As more hospitals respond to health information technology meaningful use incentives, thoughtful, methodical, and well-managed approaches to technology deployment are crucial. This work illustrates how Jidoka offers opportunities for a smooth transition to new technology.

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation

PubMed Central

Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J

2014-01-01

Objective To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. Materials and methods We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug–allergy, drug–drug interaction, and drug–disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Results Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1–5) compared to original alerts: 4 (1–7); p=0.024). Discussion Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. Conclusions This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. PMID:24668841

Applying human factors principles to alert design increases efficiency and reduces prescribing errors in a scenario-based simulation.

PubMed

Russ, Alissa L; Zillich, Alan J; Melton, Brittany L; Russell, Scott A; Chen, Siying; Spina, Jeffrey R; Weiner, Michael; Johnson, Elizabette G; Daggy, Joanne K; McManus, M Sue; Hawsey, Jason M; Puleo, Anthony G; Doebbeling, Bradley N; Saleem, Jason J

2014-10-01

To apply human factors engineering principles to improve alert interface design. We hypothesized that incorporating human factors principles into alerts would improve usability, reduce workload for prescribers, and reduce prescribing errors. We performed a scenario-based simulation study using a counterbalanced, crossover design with 20 Veterans Affairs prescribers to compare original versus redesigned alerts. We redesigned drug-allergy, drug-drug interaction, and drug-disease alerts based upon human factors principles. We assessed usability (learnability of redesign, efficiency, satisfaction, and usability errors), perceived workload, and prescribing errors. Although prescribers received no training on the design changes, prescribers were able to resolve redesigned alerts more efficiently (median (IQR): 56 (47) s) compared to the original alerts (85 (71) s; p=0.015). In addition, prescribers rated redesigned alerts significantly higher than original alerts across several dimensions of satisfaction. Redesigned alerts led to a modest but significant reduction in workload (p=0.042) and significantly reduced the number of prescribing errors per prescriber (median (range): 2 (1-5) compared to original alerts: 4 (1-7); p=0.024). Aspects of the redesigned alerts that likely contributed to better prescribing include design modifications that reduced usability-related errors, providing clinical data closer to the point of decision, and displaying alert text in a tabular format. Displaying alert text in a tabular format may help prescribers extract information quickly and thereby increase responsiveness to alerts. This simulation study provides evidence that applying human factors design principles to medication alerts can improve usability and prescribing outcomes. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Evaluating the Performance Diagnostic Checklist-Human Services to Assess Incorrect Error-Correction Procedures by Preschool Paraprofessionals

ERIC Educational Resources Information Center

Bowe, Melissa; Sellers, Tyra P.

2018-01-01

The Performance Diagnostic Checklist-Human Services (PDC-HS) has been used to assess variables contributing to undesirable staff performance. In this study, three preschool teachers completed the PDC-HS to identify the factors contributing to four paraprofessionals' inaccurate implementation of error-correction procedures during discrete trial…

The Importance of HRA in Human Space Flight: Understanding the Risks

NASA Technical Reports Server (NTRS)

Hamlin, Teri

2010-01-01

Human performance is critical to crew safety during space missions. Humans interact with hardware and software during ground processing, normal flight, and in response to events. Human interactions with hardware and software can cause Loss of Crew and/or Vehicle (LOCV) through improper actions, or may prevent LOCV through recovery and control actions. Humans have the ability to deal with complex situations and system interactions beyond the capability of machines. Human Reliability Analysis (HRA) is a method used to qualitatively and quantitatively assess the occurrence of human failures that affect availability and reliability of complex systems. Modeling human actions with their corresponding failure probabilities in a Probabilistic Risk Assessment (PRA) provides a more complete picture of system risks and risk contributions. A high-quality HRA can provide valuable information on potential areas for improvement, including training, procedures, human interfaces design, and the need for automation. Modeling human error has always been a challenge in part because performance data is not always readily available. For spaceflight, the challenge is amplified not only because of the small number of participants and limited amount of performance data available, but also due to the lack of definition of the unique factors influencing human performance in space. These factors, called performance shaping factors in HRA terminology, are used in HRA techniques to modify basic human error probabilities in order to capture the context of an analyzed task. Many of the human error modeling techniques were developed within the context of nuclear power plants and therefore the methodologies do not address spaceflight factors such as the effects of microgravity and longer duration missions. This presentation will describe the types of human error risks which have shown up as risk drivers in the Shuttle PRA which may be applicable to commercial space flight. As with other large PRAs of complex machines, human error in the Shuttle PRA proved to be an important contributor (12 percent) to LOCV. An existing HRA technique was adapted for use in the Shuttle PRA, but additional guidance and improvements are needed to make the HRA task in space-related PRAs easier and more accurate. Therefore, this presentation will also outline plans for expanding current HRA methodology to more explicitly cover spaceflight performance shaping factors.

Comment on "Differential sensitivity to human communication in dogs, wolves, and human infants".

PubMed

Fiset, Sylvain

2010-07-09

Topál et al. (Reports, 4 September 2009, p. 1269) reported that dogs' sensitivity to reading and using human signals contributes to the emergence of a spatial perseveration error (the A-not-B error) for locating objects. Here, I argue that the authors' conclusion was biased by two confounding factors: the use of an atypical A-not-B search task and an inadequate nonsocial condition as a control.

NASA: Model development for human factors interfacing

NASA Technical Reports Server (NTRS)

Smith, L. L.

1984-01-01

The results of an intensive literature review in the general topics of human error analysis, stress and job performance, and accident and safety analysis revealed no usable techniques or approaches for analyzing human error in ground or space operations tasks. A task review model is described and proposed to be developed in order to reduce the degree of labor intensiveness in ground and space operations tasks. An extensive number of annotated references are provided.

Designing to Control Flight Crew Errors

NASA Technical Reports Server (NTRS)

Schutte, Paul C.; Willshire, Kelli F.

1997-01-01

It is widely accepted that human error is a major contributing factor in aircraft accidents. There has been a significant amount of research in why these errors occurred, and many reports state that the design of flight deck can actually dispose humans to err. This research has led to the call for changes in design according to human factors and human-centered principles. The National Aeronautics and Space Administration's (NASA) Langley Research Center has initiated an effort to design a human-centered flight deck from a clean slate (i.e., without constraints of existing designs.) The effort will be based on recent research in human-centered design philosophy and mission management categories. This design will match the human's model of the mission and function of the aircraft to reduce unnatural or non-intuitive interfaces. The product of this effort will be a flight deck design description, including training and procedures, and a cross reference or paper trail back to design hypotheses, and an evaluation of the design. The present paper will discuss the philosophy, process, and status of this design effort.

Causes and Prevention of Laparoscopic Bile Duct Injuries

PubMed Central

Way, Lawrence W.; Stewart, Lygia; Gantert, Walter; Liu, Kingsway; Lee, Crystine M.; Whang, Karen; Hunter, John G.

2003-01-01

Objective To apply human performance concepts in an attempt to understand the causes of and prevent laparoscopic bile duct injury. Summary Background Data Powerful conceptual advances have been made in understanding the nature and limits of human performance. Applying these findings in high-risk activities, such as commercial aviation, has allowed the work environment to be restructured to substantially reduce human error. Methods The authors analyzed 252 laparoscopic bile duct injuries according to the principles of the cognitive science of visual perception, judgment, and human error. The injury distribution was class I, 7%; class II, 22%; class III, 61%; and class IV, 10%. The data included operative radiographs, clinical records, and 22 videotapes of original operations. Results The primary cause of error in 97% of cases was a visual perceptual illusion. Faults in technical skill were present in only 3% of injuries. Knowledge and judgment errors were contributory but not primary. Sixty-four injuries (25%) were recognized at the index operation; the surgeon identified the problem early enough to limit the injury in only 15 (6%). In class III injuries the common duct, erroneously believed to be the cystic duct, was deliberately cut. This stemmed from an illusion of object form due to a specific uncommon configuration of the structures and the heuristic nature (unconscious assumptions) of human visual perception. The videotapes showed the persuasiveness of the illusion, and many operative reports described the operation as routine. Class II injuries resulted from a dissection too close to the common hepatic duct. Fundamentally an illusion, it was contributed to in some instances by working too deep in the triangle of Calot. Conclusions These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecystectomy where the complication-causing errors occur, which suggests that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury. PMID:12677139

Advancing Usability Evaluation through Human Reliability Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ronald L. Boring; David I. Gertman

2005-07-01

This paper introduces a novel augmentation to the current heuristic usability evaluation methodology. The SPAR-H human reliability analysis method was developed for categorizing human performance in nuclear power plants. Despite the specialized use of SPAR-H for safety critical scenarios, the method also holds promise for use in commercial off-the-shelf software usability evaluations. The SPAR-H method shares task analysis underpinnings with human-computer interaction, and it can be easily adapted to incorporate usability heuristics as performance shaping factors. By assigning probabilistic modifiers to heuristics, it is possible to arrive at the usability error probability (UEP). This UEP is not a literal probabilitymore » of error but nonetheless provides a quantitative basis to heuristic evaluation. When combined with a consequence matrix for usability errors, this method affords ready prioritization of usability issues.« less

Autonomous Control Modes and Optimized Path Guidance for Shipboard Landing in High Sea States

DTIC Science & Technology

2015-11-16

a degraded visual environment, workload during the landing task begins to approach the limits of a human pilot’s capability. It is a similarly...Figure 2. Approach Trajectory ±4 ft landing error ±8 ft landing error ±12 ft landing error Flight Path -3000...heave and yaw axes. Figure 5. Open loop system generation ±4 ft landing error ±8 ft landing error ±12 ft landing error -10 -8 -6 -4 -2 0 2 4

The Accuracy of GBM GRB Localizations

NASA Astrophysics Data System (ADS)

Briggs, Michael Stephen; Connaughton, V.; Meegan, C.; Hurley, K.

2010-03-01

We report an study of the accuracy of GBM GRB localizations, analyzing three types of localizations: those produced automatically by the GBM Flight Software on board GBM, those produced automatically with ground software in near real time, and localizations produced with human guidance. The two types of automatic locations are distributed in near real-time via GCN Notices; the human-guided locations are distributed on timescale of many minutes or hours using GCN Circulars. This work uses a Bayesian analysis that models the distribution of the GBM total location error by comparing GBM locations to more accurate locations obtained with other instruments. Reference locations are obtained from Swift, Super-AGILE, the LAT, and with the IPN. We model the GBM total location errors as having systematic errors in addition to the statistical errors and use the Bayesian analysis to constrain the systematic errors.

THERP and HEART integrated methodology for human error assessment

NASA Astrophysics Data System (ADS)

Castiglia, Francesco; Giardina, Mariarosa; Tomarchio, Elio

2015-11-01

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.

Patient safety in otolaryngology: a descriptive review.

PubMed

Danino, Julian; Muzaffar, Jameel; Metcalfe, Chris; Coulson, Chris

2017-03-01

Human evaluation and judgement may include errors that can have disastrous results. Within medicine and healthcare there has been slow progress towards major changes in safety. Healthcare lags behind other specialised industries, such as aviation and nuclear power, where there have been significant improvements in overall safety, especially in reducing risk of errors. Following several high profile cases in the USA during the 1990s, a report titled "To Err Is Human: Building a Safer Health System" was published. The report extrapolated that in the USA approximately 50,000 to 100,000 patients may die each year as a result of medical errors. Traditionally otolaryngology has always been regarded as a "safe specialty". A study in the USA in 2004 inferred that there may be 2600 cases of major morbidity and 165 deaths within the specialty. MEDLINE via PubMed interface was searched for English language articles published between 2000 and 2012. Each combined two or three of the keywords noted earlier. Limitations are related to several generic topics within patient safety in otolaryngology. Other areas covered have been current relevant topics due to recent interest or new advances in technology. There has been a heightened awareness within the healthcare community of patient safety; it has become a major priority. Focus has shifted from apportioning blame to prevention of the errors and implementation of patient safety mechanisms in healthcare delivery. Type of Errors can be divided into errors due to action and errors due to knowledge or planning. In healthcare there are several factors that may influence adverse events and patient safety. Although technology may improve patient safety, it also introduces new sources of error. The ability to work with people allows for the increase in safety netting. Team working has been shown to have a beneficial effect on patient safety. Any field of work involving human decision-making will always have a risk of error. Within Otolaryngology, although patient safety has evolved along similar themes as other surgical specialties; there are several specific high-risk areas. Medical error is a common problem and its human cost is of immense importance. Steps to reduce such errors require the identification of high-risk practice within a complex healthcare system. The commitment to patient safety and quality improvement in medicine depend on personal responsibility and professional accountability.

Error identification and recovery by student nurses using human patient simulation: opportunity to improve patient safety.

PubMed

Henneman, Elizabeth A; Roche, Joan P; Fisher, Donald L; Cunningham, Helene; Reilly, Cheryl A; Nathanson, Brian H; Henneman, Philip L

2010-02-01

This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance. Copyright 2010 Elsevier Inc. All rights reserved.

Advanced automated glass cockpit certification: Being wary of human factors

NASA Technical Reports Server (NTRS)

Amalberti, Rene; Wilbaux, Florence

1994-01-01

This paper presents some facets of the French experience with human factors in the process of certification of advanced automated cockpits. Three types of difficulties are described: first, the difficulties concerning the hotly debated concept of human error and its non-linear relationship to risk of accident; a typology of errors to be taken into account in the certification process is put forward to respond to this issue. Next, the difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. The last difficulties to be considered are those related to the goals of certification itself on these new aircraft and the status of findings from human factor analyses (in particular, what should be done with disappointing results, how much can the changes induced by human factors investigation economically affect aircraft design, how many errors do we need to accumulate before we revise the system, what should be remedied when human factor problems are discovered at the certification stage: the machine? pilot training? the rules? or everything?). The growth of advanced-automated glass cockpits has forced the international aeronautical community to pay more attention to human factors during the design phase, the certification phase and pilot training. The recent creation of a human factor desk at the DGAC-SFACT (Official French services) is a direct consequence of this. The paper is divided into three parts. Part one debates human error and its relationship with system design and accident risk. Part two describes difficulties connected to the basically gradual and evolving nature of pilot expertise on a given type of aircraft, which contrasts with the immediate and definitive style of certifying systems. Part three focuses on concrete outcomes of human factors for certification purposes.

Normal accidents: human error and medical equipment design.

PubMed

Dain, Steven

2002-01-01

High-risk systems, which are typical of our technologically complex era, include not just nuclear power plants but also hospitals, anesthesia systems, and the practice of medicine and perfusion. In high-risk systems, no matter how effective safety devices are, some types of accidents are inevitable because the system's complexity leads to multiple and unexpected interactions. It is important for healthcare providers to apply a risk assessment and management process to decisions involving new equipment and procedures or staffing matters in order to minimize the residual risks of latent errors, which are amenable to correction because of the large window of opportunity for their detection. This article provides an introduction to basic risk management and error theory principles and examines ways in which they can be applied to reduce and mitigate the inevitable human errors that accompany high-risk systems. The article also discusses "human factor engineering" (HFE), the process which is used to design equipment/ human interfaces in order to mitigate design errors. The HFE process involves interaction between designers and endusers to produce a series of continuous refinements that are incorporated into the final product. The article also examines common design problems encountered in the operating room that may predispose operators to commit errors resulting in harm to the patient. While recognizing that errors and accidents are unavoidable, organizations that function within a high-risk system must adopt a "safety culture" that anticipates problems and acts aggressively through an anonymous, "blameless" reporting mechanism to resolve them. We must continuously examine and improve the design of equipment and procedures, personnel, supplies and materials, and the environment in which we work to reduce error and minimize its effects. Healthcare providers must take a leading role in the day-to-day management of the "Perioperative System" and be a role model in promoting a culture of safety in their organizations.

The introduction of an acute physiological support service for surgical patients is an effective error reduction strategy.

PubMed

Clarke, D L; Kong, V Y; Naidoo, L C; Furlong, H; Aldous, C

2013-01-01

Acute surgical patients are particularly vulnerable to human error. The Acute Physiological Support Team (APST) was created with the twin objectives of identifying high-risk acute surgical patients in the general wards and reducing both the incidence of error and impact of error on these patients. A number of error taxonomies were used to understand the causes of human error and a simple risk stratification system was adopted to identify patients who are particularly at risk of error. During the period November 2012-January 2013 a total of 101 surgical patients were cared for by the APST at Edendale Hospital. The average age was forty years. There were 36 females and 65 males. There were 66 general surgical patients and 35 trauma patients. Fifty-six patients were referred on the day of their admission. The average length of stay in the APST was four days. Eleven patients were haemo-dynamically unstable on presentation and twelve were clinically septic. The reasons for referral were sepsis,(4) respiratory distress,(3) acute kidney injury AKI (38), post-operative monitoring (39), pancreatitis,(3) ICU down-referral,(7) hypoxia,(5) low GCS,(1) coagulopathy.(1) The mortality rate was 13%. A total of thirty-six patients experienced 56 errors. A total of 143 interventions were initiated by the APST. These included institution or adjustment of intravenous fluids (101), blood transfusion,(12) antibiotics,(9) the management of neutropenic sepsis,(1) central line insertion,(3) optimization of oxygen therapy,(7) correction of electrolyte abnormality,(8) correction of coagulopathy.(2) CONCLUSION: Our intervention combined current taxonomies of error with a simple risk stratification system and is a variant of the defence in depth strategy of error reduction. We effectively identified and corrected a significant number of human errors in high-risk acute surgical patients. This audit has helped understand the common sources of error in the general surgical wards and will inform on-going error reduction initiatives. Copyright © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

A framework for human-hydrologic system model development integrating hydrology and water management: application to the Cutzamala water system in Mexico

NASA Astrophysics Data System (ADS)

Wi, S.; Freeman, S.; Brown, C.

2017-12-01

This study presents a general approach to developing computational models of human-hydrologic systems where human modification of hydrologic surface processes are significant or dominant. A river basin system is represented by a network of human-hydrologic response units (HHRUs) identified based on locations where river regulations happen (e.g., reservoir operation and diversions). Natural and human processes in HHRUs are simulated in a holistic framework that integrates component models representing rainfall-runoff, river routing, reservoir operation, flow diversion and water use processes. We illustrate the approach in a case study of the Cutzamala water system (CWS) in Mexico, a complex inter-basin water transfer system supplying the Mexico City Metropolitan Area (MCMA). The human-hydrologic system model for CWS (CUTZSIM) is evaluated in terms of streamflow and reservoir storages measured across the CWS and to water supplied for MCMA. The CUTZSIM improves the representation of hydrology and river-operation interaction and, in so doing, advances evaluation of system-wide water management consequences under altered climatic and demand regimes. The integrated modeling framework enables evaluation and simulation of model errors throughout the river basin, including errors in representation of the human component processes. Heretofore, model error evaluation, predictive error intervals and the resultant improved understanding have been limited to hydrologic processes. The general framework represents an initial step towards fuller understanding and prediction of the many and varied processes that determine the hydrologic fluxes and state variables in real river basins.

A Foundation for Systems Anthropometry: Lumbar/Pelvic Kinematics

DTIC Science & Technology

1983-02-01

caused by human error in positioning the cursor of the digitizing board and inaccuracy of the digitizer. (Human error is approximately + .02 an and...Milne, J.S. and Lauder, I.J. 1974. "Age Effects in Kyphosis and Lordosis in Adults." Ann. Hum. Biol. 1(3):327-337. Mchr, G.C., Brinkley, J.W., Kazarian

Comment on "Differential sensitivity to human communication in dogs, wolves, and human infants".

PubMed

Marshall-Pescini, S; Passalacqua, C; Valsecchi, P; Prato-Previde, E

2010-07-09

Topál et al. (Reports, 4 September 2009, p. 1269) showed that dogs, like infants but unlike wolves, make perseverative search errors that can be explained by the use of ostensive cues from the experimenter. We suggest that a simpler learning process, local enhancement, can account for errors made by dogs.

Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions

DTIC Science & Technology

2018-03-20

USAARL Report No. 2018-08 Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions By Kathryn A...3 Statistical Analysis Approach ..............................................................................................3 Results...1 Introduction The success of unmanned aerial systems (UAS) operations relies upon a variety of factors, including, but not limited to

Impact of human error on lumber yield in rough mills

Treesearch

Urs Buehlmann; R. Edward Thomas; R. Edward Thomas

2002-01-01

Rough sawn, kiln-dried lumber contains characteristics such as knots and bark pockets that are considered by most people to be defects. When using boards to produce furniture components, these defects are removed to produce clear, defect-free parts. Currently, human operators identify and locate the unusable board areas containing defects. Errors in determining a...

Action errors, error management, and learning in organizations.

PubMed

Frese, Michael; Keith, Nina

2015-01-03

Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.

Review of Significant Incidents and Close Calls in Human Spaceflight from a Human Factors Perspective

NASA Technical Reports Server (NTRS)

Silva-Martinez, Jackelynne; Ellenberger, Richard; Dory, Jonathan

2017-01-01

This project aims to identify poor human factors design decisions that led to error-prone systems, or did not facilitate the flight crew making the right choices; and to verify that NASA is effectively preventing similar incidents from occurring again. This analysis was performed by reviewing significant incidents and close calls in human spaceflight identified by the NASA Johnson Space Center Safety and Mission Assurance Flight Safety Office. The review of incidents shows whether the identified human errors were due to the operational phase (flight crew and ground control) or if they initiated at the design phase (includes manufacturing and test). This classification was performed with the aid of the NASA Human Systems Integration domains. This in-depth analysis resulted in a tool that helps with the human factors classification of significant incidents and close calls in human spaceflight, which can be used to identify human errors at the operational level, and how they were or should be minimized. Current governing documents on human systems integration for both government and commercial crew were reviewed to see if current requirements, processes, training, and standard operating procedures protect the crew and ground control against these issues occurring in the future. Based on the findings, recommendations to target those areas are provided.

Uncorrected refractive errors.

PubMed

Naidoo, Kovin S; Jaggernath, Jyoti

2012-01-01

Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship.

Intelligent OCR Processing.

ERIC Educational Resources Information Center

Sun, Wei; And Others

1992-01-01

Identifies types and distributions of errors in text produced by optical character recognition (OCR) and proposes a process using machine learning techniques to recognize and correct errors in OCR texts. Results of experiments indicating that this strategy can reduce human interaction required for error correction are reported. (25 references)…

Immortalization of normal human mammary epithelial cells in two steps by direct targeting of senescence barriers does not require gross genomic alterations

DOE PAGES

Garbe, James C.; Vrba, Lukas; Sputova, Klara; ...

2014-10-29

Telomerase reactivation and immortalization are critical for human carcinoma progression. However, little is known about the mechanisms controlling this crucial step, due in part to the paucity of experimentally tractable model systems that can examine human epithelial cell immortalization as it might occur in vivo. We achieved efficient non-clonal immortalization of normal human mammary epithelial cells (HMEC) by directly targeting the 2 main senescence barriers encountered by cultured HMEC. The stress-associated stasis barrier was bypassed using shRNA to p16INK4; replicative senescence due to critically shortened telomeres was bypassed in post-stasis HMEC by c-MYC transduction. Thus, 2 pathologically relevant oncogenic agentsmore » are sufficient to immortally transform normal HMEC. The resultant non-clonal immortalized lines exhibited normal karyotypes. Most human carcinomas contain genomically unstable cells, with widespread instability first observed in vivo in pre-malignant stages; in vitro, instability is seen as finite cells with critically shortened telomeres approach replicative senescence. Our results support our hypotheses that: (1) telomere-dysfunction induced genomic instability in pre-malignant finite cells may generate the errors required for telomerase reactivation and immortalization, as well as many additional “passenger” errors carried forward into resulting carcinomas; (2) genomic instability during cancer progression is needed to generate errors that overcome tumor suppressive barriers, but not required per se; bypassing the senescence barriers by direct targeting eliminated a need for genomic errors to generate immortalization. Achieving efficient HMEC immortalization, in the absence of “passenger” genomic errors, should facilitate examination of telomerase regulation during human carcinoma progression, and exploration of agents that could prevent immortalization.« less

Recognizing and managing errors of cognitive underspecification.

PubMed

Duthie, Elizabeth A

2014-03-01

James Reason describes cognitive underspecification as incomplete communication that creates a knowledge gap. Errors occur when an information mismatch occurs in bridging that gap with a resulting lack of shared mental models during the communication process. There is a paucity of studies in health care examining this cognitive error and the role it plays in patient harm. The goal of the following case analyses is to facilitate accurate recognition, identify how it contributes to patient harm, and suggest appropriate management strategies. Reason's human error theory is applied in case analyses of errors of cognitive underspecification. Sidney Dekker's theory of human incident investigation is applied to event investigation to facilitate identification of this little recognized error. Contributory factors leading to errors of cognitive underspecification include workload demands, interruptions, inexperienced practitioners, and lack of a shared mental model. Detecting errors of cognitive underspecification relies on blame-free listening and timely incident investigation. Strategies for interception include two-way interactive communication, standardization of communication processes, and technological support to ensure timely access to documented clinical information. Although errors of cognitive underspecification arise at the sharp end with the care provider, effective management is dependent upon system redesign that mitigates the latent contributory factors. Cognitive underspecification is ubiquitous whenever communication occurs. Accurate identification is essential if effective system redesign is to occur.

Comprehensive analysis of a medication dosing error related to CPOE.

PubMed

Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L

2005-01-01

This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

78 FR 17155 - Standards for the Growing, Harvesting, Packing, and Holding of Produce for Human Consumption...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-20

...The Food and Drug Administration (FDA or we) is correcting the preamble to a proposed rule that published in the Federal Register of January 16, 2013. That proposed rule would establish science-based minimum standards for the safe growing, harvesting, packing, and holding of produce, meaning fruits and vegetables grown for human consumption. FDA proposed these standards as part of our implementation of the FDA Food Safety Modernization Act. The document published with several technical errors, including some errors in cross references, as well as several errors in reference numbers cited throughout the document. This document corrects those errors. We are also placing a corrected copy of the proposed rule in the docket.

Patient identification using a near-infrared laser scanner

NASA Astrophysics Data System (ADS)

Manit, Jirapong; Bremer, Christina; Schweikard, Achim; Ernst, Floris

2017-03-01

We propose a new biometric approach where the tissue thickness of a person's forehead is used as a biometric feature. Given that the spatial registration of two 3D laser scans of the same human face usually produces a low error value, the principle of point cloud registration and its error metric can be applied to human classification techniques. However, by only considering the spatial error, it is not possible to reliably verify a person's identity. We propose to use a novel near-infrared laser-based head tracking system to determine an additional feature, the tissue thickness, and include this in the error metric. Using MRI as a ground truth, data from the foreheads of 30 subjects was collected from which a 4D reference point cloud was created for each subject. The measurements from the near-infrared system were registered with all reference point clouds using the ICP algorithm. Afterwards, the spatial and tissue thickness errors were extracted, forming a 2D feature space. For all subjects, the lowest feature distance resulted from the registration of a measurement and the reference point cloud of the same person. The combined registration error features yielded two clusters in the feature space, one from the same subject and another from the other subjects. When only the tissue thickness error was considered, these clusters were less distinct but still present. These findings could help to raise safety standards for head and neck cancer patients and lays the foundation for a future human identification technique.

Human factors evaluation of remote afterloading brachytherapy. Volume 2, Function and task analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Callan, J.R.; Gwynne, J.W. III; Kelly, T.T.

1995-05-01

A human factors project on the use of nuclear by-product material to treat cancer using remotely operated afterloaders was undertaken by the Nuclear Regulatory Commission. The purpose of the project was to identify factors that contribute to human error in the system for remote afterloading brachytherapy (RAB). This report documents the findings from the first phase of the project, which involved an extensive function and task analysis of RAB. This analysis identified the functions and tasks in RAB, made preliminary estimates of the likelihood of human error in each task, and determined the skills needed to perform each RAB task.more » The findings of the function and task analysis served as the foundation for the remainder of the project, which evaluated four major aspects of the RAB system linked to human error: human-system interfaces; procedures and practices; training and qualifications of RAB staff; and organizational practices and policies. At its completion, the project identified and prioritized areas for recommended NRC and industry attention based on all of the evaluations and analyses.« less

Prediction error induced motor contagions in human behaviors.

PubMed

Ikegami, Tsuyoshi; Ganesh, Gowrishankar; Takeuchi, Tatsuya; Nakamoto, Hiroki

2018-05-29

Motor contagions refer to implicit effects on one's actions induced by observed actions. Motor contagions are believed to be induced simply by action observation and cause an observer's action to become similar to the action observed. In contrast, here we report a new motor contagion that is induced only when the observation is accompanied by prediction errors - differences between actions one observes and those he/she predicts or expects. In two experiments, one on whole-body baseball pitching and another on simple arm reaching, we show that the observation of the same action induces distinct motor contagions, depending on whether prediction errors are present or not. In the absence of prediction errors, as in previous reports, participants' actions changed to become similar to the observed action, while in the presence of prediction errors, their actions changed to diverge away from it, suggesting distinct effects of action observation and action prediction on human actions. © 2018, Ikegami et al.

Synchronizing movements with the metronome: nonlinear error correction and unstable periodic orbits.

PubMed

Engbert, Ralf; Krampe, Ralf Th; Kurths, Jürgen; Kliegl, Reinhold

2002-02-01

The control of human hand movements is investigated in a simple synchronization task. We propose and analyze a stochastic model based on nonlinear error correction; a mechanism which implies the existence of unstable periodic orbits. This prediction is tested in an experiment with human subjects. We find that our experimental data are in good agreement with numerical simulations of our theoretical model. These results suggest that feedback control of the human motor systems shows nonlinear behavior. Copyright 2001 Elsevier Science (USA).

Human error in aviation operations

NASA Technical Reports Server (NTRS)

Billings, C. E.; Lanber, J. K.; Cooper, G. E.

1974-01-01

This report is a brief description of research being undertaken by the National Aeronautics and Space Administration. The project is designed to seek out factors in the aviation system which contribute to human error, and to search for ways of minimizing the potential threat posed by these factors. The philosophy and assumptions underlying the study are discussed, together with an outline of the research plan.

Human Factors Directions for Civil Aviation

NASA Technical Reports Server (NTRS)

Hart, Sandra G.

2002-01-01

Despite considerable progress in understanding human capabilities and limitations, incorporating human factors into aircraft design, operation, and certification, and the emergence of new technologies designed to reduce workload and enhance human performance in the system, most aviation accidents still involve human errors. Such errors occur as a direct or indirect result of untimely, inappropriate, or erroneous actions (or inactions) by apparently well-trained and experienced pilots, controllers, and maintainers. The field of human factors has solved many of the more tractable problems related to simple ergonomics, cockpit layout, symbology, and so on. We have learned much about the relationships between people and machines, but know less about how to form successful partnerships between humans and the information technologies that are beginning to play a central role in aviation. Significant changes envisioned in the structure of the airspace, pilots and controllers' roles and responsibilities, and air/ground technologies will require a similarly significant investment in human factors during the next few decades to ensure the effective integration of pilots, controllers, dispatchers, and maintainers into the new system. Many of the topics that will be addressed are not new because progress in crucial areas, such as eliminating human error, has been slow. A multidisciplinary approach that capitalizes upon human studies and new classes of information, computational models, intelligent analytical tools, and close collaborations with organizations that build, operate, and regulate aviation technology will ensure that the field of human factors meets the challenge.

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2013 CFR

2013-10-01

....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2014 CFR

2014-10-01

....102 Public Welfare Department of Health and Human Services GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2012 CFR

2012-10-01

....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.102 - Content of Error Rate Reports.

Code of Federal Regulations, 2011 CFR

2011-10-01

....102 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND Error Rate Reporting § 98.102 Content of Error Rate Reports. (a) Baseline Submission Report... payments by the total dollar amount of child care payments that the State, the District of Columbia or...

45 CFR 98.100 - Error Rate Report.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION CHILD CARE AND DEVELOPMENT FUND... rates, which is defined as the percentage of cases with an error (expressed as the total number of cases with an error compared to the total number of cases); the percentage of cases with an improper payment...

42 CFR 407.32 - Prejudice to enrollment rights because of Federal Government misrepresentation, inaction, or error.

Code of Federal Regulations, 2010 CFR

2010-10-01

... Government misrepresentation, inaction, or error. 407.32 Section 407.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE... enrollment rights because of Federal Government misrepresentation, inaction, or error. If an individual's...

42 CFR 407.32 - Prejudice to enrollment rights because of Federal Government misrepresentation, inaction, or error.

Code of Federal Regulations, 2011 CFR

2011-10-01

... Government misrepresentation, inaction, or error. 407.32 Section 407.32 Public Health CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICARE PROGRAM SUPPLEMENTARY MEDICAL INSURANCE... enrollment rights because of Federal Government misrepresentation, inaction, or error. If an individual's...

Can eye-tracking technology improve situational awareness in paramedic clinical education?

PubMed

Williams, Brett; Quested, Andrew; Cooper, Simon

2013-01-01

Human factors play a significant part in clinical error. Situational awareness (SA) means being aware of one's surroundings, comprehending the present situation, and being able to predict outcomes. It is a key human skill that, when properly applied, is associated with reducing medical error: eye-tracking technology can be used to provide an objective and qualitative measure of the initial perception component of SA. Feedback from eye-tracking technology can be used to improve the understanding and teaching of SA in clinical contexts, and consequently, has potential for reducing clinician error and the concomitant adverse events.

Recognizing the Ordinary as Extraordinary: Insight Into the "Way We Work" to Improve Patient Safety Outcomes.

PubMed

Henneman, Elizabeth A

2017-07-01

The Institute of Medicine (now National Academy of Medicine) reports "To Err is Human" and "Crossing the Chasm" made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the "near miss" process and as the final safety net for the patient is of paramount importance. The nurse's role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies. ©2017 American Association of Critical-Care Nurses.

Preventing medical errors by designing benign failures.

PubMed

Grout, John R

2003-07-01

One way to successfully reduce medical errors is to design health care systems that are more resistant to the tendencies of human beings to err. One interdisciplinary approach entails creating design changes, mitigating human errors, and making human error irrelevant to outcomes. This approach is intended to facilitate the creation of benign failures, which have been called mistake-proofing devices and forcing functions elsewhere. USING FAULT TREES TO DESIGN FORCING FUNCTIONS: A fault tree is a graphical tool used to understand the relationships that either directly cause or contribute to the cause of a particular failure. A careful analysis of a fault tree enables the analyst to anticipate how the process will behave after the change. EXAMPLE OF AN APPLICATION: A scenario in which a patient is scalded while bathing can serve as an example of how multiple fault trees can be used to design forcing functions. The first fault tree shows the undesirable event--patient scalded while bathing. The second fault tree has a benign event--no water. Adding a scald valve changes the outcome from the undesirable event ("patient scalded while bathing") to the benign event ("no water") Analysis of fault trees does not ensure or guarantee that changes necessary to eliminate error actually occur. Most mistake-proofing is used to prevent simple errors and to create well-defended processes, but complex errors can also result. The utilization of mistake-proofing or forcing functions can be thought of as changing the logic of a process. Errors that formerly caused undesirable failures can be converted into the causes of benign failures. The use of fault trees can provide a variety of insights into the design of forcing functions that will improve patient safety.

Comparison of software and human observers in reading images of the CDMAM test object to assess digital mammography systems

NASA Astrophysics Data System (ADS)

Young, Kenneth C.; Cook, James J. H.; Oduko, Jennifer M.; Bosmans, Hilde

2006-03-01

European Guidelines for quality control in digital mammography specify minimum and achievable standards of image quality in terms of threshold contrast, based on readings of images of the CDMAM test object by human observers. However this is time-consuming and has large inter-observer error. To overcome these problems a software program (CDCOM) is available to automatically read CDMAM images, but the optimal method of interpreting the output is not defined. This study evaluates methods of determining threshold contrast from the program, and compares these to human readings for a variety of mammography systems. The methods considered are (A) simple thresholding (B) psychometric curve fitting (C) smoothing and interpolation and (D) smoothing and psychometric curve fitting. Each method leads to similar threshold contrasts but with different reproducibility. Method (A) had relatively poor reproducibility with a standard error in threshold contrast of 18.1 +/- 0.7%. This was reduced to 8.4% by using a contrast-detail curve fitting procedure. Method (D) had the best reproducibility with an error of 6.7%, reducing to 5.1% with curve fitting. A panel of 3 human observers had an error of 4.4% reduced to 2.9 % by curve fitting. All automatic methods led to threshold contrasts that were lower than for humans. The ratio of human to program threshold contrasts varied with detail diameter and was 1.50 +/- .04 (sem) at 0.1mm and 1.82 +/- .06 at 0.25mm for method (D). There were good correlations between the threshold contrast determined by humans and the automated methods.

Uncorrected refractive errors

PubMed Central

Naidoo, Kovin S; Jaggernath, Jyoti

2012-01-01

Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship. PMID:22944755

Distinct prediction errors in mesostriatal circuits of the human brain mediate learning about the values of both states and actions: evidence from high-resolution fMRI.

PubMed

Colas, Jaron T; Pauli, Wolfgang M; Larsen, Tobias; Tyszka, J Michael; O'Doherty, John P

2017-10-01

Prediction-error signals consistent with formal models of "reinforcement learning" (RL) have repeatedly been found within dopaminergic nuclei of the midbrain and dopaminoceptive areas of the striatum. However, the precise form of the RL algorithms implemented in the human brain is not yet well determined. Here, we created a novel paradigm optimized to dissociate the subtypes of reward-prediction errors that function as the key computational signatures of two distinct classes of RL models-namely, "actor/critic" models and action-value-learning models (e.g., the Q-learning model). The state-value-prediction error (SVPE), which is independent of actions, is a hallmark of the actor/critic architecture, whereas the action-value-prediction error (AVPE) is the distinguishing feature of action-value-learning algorithms. To test for the presence of these prediction-error signals in the brain, we scanned human participants with a high-resolution functional magnetic-resonance imaging (fMRI) protocol optimized to enable measurement of neural activity in the dopaminergic midbrain as well as the striatal areas to which it projects. In keeping with the actor/critic model, the SVPE signal was detected in the substantia nigra. The SVPE was also clearly present in both the ventral striatum and the dorsal striatum. However, alongside these purely state-value-based computations we also found evidence for AVPE signals throughout the striatum. These high-resolution fMRI findings suggest that model-free aspects of reward learning in humans can be explained algorithmically with RL in terms of an actor/critic mechanism operating in parallel with a system for more direct action-value learning.

Distinct prediction errors in mesostriatal circuits of the human brain mediate learning about the values of both states and actions: evidence from high-resolution fMRI

PubMed Central

Pauli, Wolfgang M.; Larsen, Tobias; Tyszka, J. Michael; O’Doherty, John P.

2017-01-01

Prediction-error signals consistent with formal models of “reinforcement learning” (RL) have repeatedly been found within dopaminergic nuclei of the midbrain and dopaminoceptive areas of the striatum. However, the precise form of the RL algorithms implemented in the human brain is not yet well determined. Here, we created a novel paradigm optimized to dissociate the subtypes of reward-prediction errors that function as the key computational signatures of two distinct classes of RL models—namely, “actor/critic” models and action-value-learning models (e.g., the Q-learning model). The state-value-prediction error (SVPE), which is independent of actions, is a hallmark of the actor/critic architecture, whereas the action-value-prediction error (AVPE) is the distinguishing feature of action-value-learning algorithms. To test for the presence of these prediction-error signals in the brain, we scanned human participants with a high-resolution functional magnetic-resonance imaging (fMRI) protocol optimized to enable measurement of neural activity in the dopaminergic midbrain as well as the striatal areas to which it projects. In keeping with the actor/critic model, the SVPE signal was detected in the substantia nigra. The SVPE was also clearly present in both the ventral striatum and the dorsal striatum. However, alongside these purely state-value-based computations we also found evidence for AVPE signals throughout the striatum. These high-resolution fMRI findings suggest that model-free aspects of reward learning in humans can be explained algorithmically with RL in terms of an actor/critic mechanism operating in parallel with a system for more direct action-value learning. PMID:29049406

Minimizing human error in radiopharmaceutical preparation and administration via a bar code-enhanced nuclear pharmacy management system.

PubMed

Hakala, John L; Hung, Joseph C; Mosman, Elton A

2012-09-01

The objective of this project was to ensure correct radiopharmaceutical administration through the use of a bar code system that links patient and drug profiles with on-site information management systems. This new combined system would minimize the amount of manual human manipulation, which has proven to be a primary source of error. The most common reason for dosing errors is improper patient identification when a dose is obtained from the nuclear pharmacy or when a dose is administered. A standardized electronic transfer of information from radiopharmaceutical preparation to injection will further reduce the risk of misadministration. Value stream maps showing the flow of the patient dose information, as well as potential points of human error, were developed. Next, a future-state map was created that included proposed corrections for the most common critical sites of error. Transitioning the current process to the future state will require solutions that address these sites. To optimize the future-state process, a bar code system that links the on-site radiology management system with the nuclear pharmacy management system was proposed. A bar-coded wristband connects the patient directly to the electronic information systems. The bar code-enhanced process linking the patient dose with the electronic information reduces the number of crucial points for human error and provides a framework to ensure that the prepared dose reaches the correct patient. Although the proposed flowchart is designed for a site with an in-house central nuclear pharmacy, much of the framework could be applied by nuclear medicine facilities using unit doses. An electronic connection between information management systems to allow the tracking of a radiopharmaceutical from preparation to administration can be a useful tool in preventing the mistakes that are an unfortunate reality for any facility.

A Human Systems Integration Perspective to Evaluating Naval Aviation Mishaps and Developing Intervention Strategies

DTIC Science & Technology

2009-12-01

SWISS CHEESE ” MODEL........................................... 16 1. Errors and Violations...16 Figure 5. Reason’s Swiss Cheese Model (After: Reason, 1990, p. 208) ........... 20 Figure 6. The HFACS Swiss Cheese Model of...become more complex. E. REASON’S “ SWISS CHEESE ” MODEL Reason’s (1990) book, Human Error, is generally regarded as the seminal work on the subject

Assisting Movement Training and Execution With Visual and Haptic Feedback.

PubMed

Ewerton, Marco; Rother, David; Weimar, Jakob; Kollegger, Gerrit; Wiemeyer, Josef; Peters, Jan; Maeda, Guilherme

2018-01-01

In the practice of motor skills in general, errors in the execution of movements may go unnoticed when a human instructor is not available. In this case, a computer system or robotic device able to detect movement errors and propose corrections would be of great help. This paper addresses the problem of how to detect such execution errors and how to provide feedback to the human to correct his/her motor skill using a general, principled methodology based on imitation learning. The core idea is to compare the observed skill with a probabilistic model learned from expert demonstrations. The intensity of the feedback is regulated by the likelihood of the model given the observed skill. Based on demonstrations, our system can, for example, detect errors in the writing of characters with multiple strokes. Moreover, by using a haptic device, the Haption Virtuose 6D, we demonstrate a method to generate haptic feedback based on a distribution over trajectories, which could be used as an auxiliary means of communication between an instructor and an apprentice. Additionally, given a performance measurement, the haptic device can help the human discover and perform better movements to solve a given task. In this case, the human first tries a few times to solve the task without assistance. Our framework, in turn, uses a reinforcement learning algorithm to compute haptic feedback, which guides the human toward better solutions.

The Error in Total Error Reduction

PubMed Central

Witnauer, James E.; Urcelay, Gonzalo P.; Miller, Ralph R.

2013-01-01

Most models of human and animal learning assume that learning is proportional to the discrepancy between a delivered outcome and the outcome predicted by all cues present during that trial (i.e., total error across a stimulus compound). This total error reduction (TER) view has been implemented in connectionist and artificial neural network models to describe the conditions under which weights between units change. Electrophysiological work has revealed that the activity of dopamine neurons is correlated with the total error signal in models of reward learning. Similar neural mechanisms presumably support fear conditioning, human contingency learning, and other types of learning. Using a computational modelling approach, we compared several TER models of associative learning to an alternative model that rejects the TER assumption in favor of local error reduction (LER), which assumes that learning about each cue is proportional to the discrepancy between the delivered outcome and the outcome predicted by that specific cue on that trial. The LER model provided a better fit to the reviewed data than the TER models. Given the superiority of the LER model with the present data sets, acceptance of TER should be tempered. PMID:23891930

Nature and Nurture: the complex genetics of myopia and refractive error

PubMed Central

Wojciechowski, Robert

2010-01-01

The refractive errors, myopia and hyperopia, are optical defects of the visual system that can cause blurred vision. Uncorrected refractive errors are the most common causes of visual impairment worldwide. It is estimated that 2.5 billion people will be affected by myopia alone with in the next decade. Experimental, epidemiological and clinical research has shown that refractive development is influenced by both environmental and genetic factors. Animal models have demonstrated that eye growth and refractive maturation during infancy are tightly regulated by visually-guided mechanisms. Observational data in human populations provide compelling evidence that environmental influences and individual behavioral factors play crucial roles in myopia susceptibility. Nevertheless, the majority of the variance of refractive error within populations is thought to be due to hereditary factors. Genetic linkage studies have mapped two dozen loci, while association studies have implicated more than 25 different genes in refractive variation. Many of these genes are involved in common biological pathways known to mediate extracellular matrix composition and regulate connective tissue remodeling. Other associated genomic regions suggest novel mechanisms in the etiology of human myopia, such as mitochondrial-mediated cell death or photoreceptor-mediated visual signal transmission. Taken together, observational and experimental studies have revealed the complex nature of human refractive variation, which likely involves variants in several genes and functional pathways. Multiway interactions between genes and/or environmental factors may also be important in determining individual risks of myopia, and may help explain the complex pattern of refractive error in human populations. PMID:21155761

Paediatric Patient Safety and the Need for Aviation Black Box Thinking to Learn From and Prevent Medication Errors.

PubMed

Huynh, Chi; Wong, Ian C K; Correa-West, Jo; Terry, David; McCarthy, Suzanne

2017-04-01

Since the publication of To Err Is Human: Building a Safer Health System in 1999, there has been much research conducted into the epidemiology, nature and causes of medication errors in children, from prescribing and supply to administration. It is reassuring to see growing evidence of improving medication safety in children; however, based on media reports, it can be seen that serious and fatal medication errors still occur. This critical opinion article examines the problem of medication errors in children and provides recommendations for research, training of healthcare professionals and a culture shift towards dealing with medication errors. There are three factors that we need to consider to unravel what is missing and why fatal medication errors still occur. (1) Who is involved and affected by the medication error? (2) What factors hinder staff and organisations from learning from mistakes? Does the fear of litigation and criminal charges deter healthcare professionals from voluntarily reporting medication errors? (3) What are the educational needs required to prevent medication errors? It is important to educate future healthcare professionals about medication errors and human factors to prevent these from happening. Further research is required to apply aviation's 'black box' principles in healthcare to record and learn from near misses and errors to prevent future events. There is an urgent need for the black box investigations to be published and made public for the benefit of other organisations that may have similar potential risks for adverse events. International sharing of investigations and learning is also needed.

Integrating Safety in the Aviation System: Interdepartmental Training for Pilots and Maintenance Technicians

NASA Technical Reports Server (NTRS)

Mattson, Marifran; Petrin, Donald A.; Young, John P.

2001-01-01

The study of human factors has had a decisive impact on the aviation industry. However, the entire aviation system often is not considered in researching, training, and evaluating human factors issues especially with regard to safety. In both conceptual and practical terms, we argue for the proactive management of human error from both an individual and organizational systems perspective. The results of a multidisciplinary research project incorporating survey data from professional pilots and maintenance technicians and an exploratory study integrating students from relevant disciplines are reported. Survey findings suggest that latent safety errors may occur during the maintenance discrepancy reporting process because pilots and maintenance technicians do not effectively interact with one another. The importance of interdepartmental or cross-disciplinary training for decreasing these errors and increasing safety is discussed as a primary implication.

Human Error and Commercial Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

DTIC Science & Technology

2006-07-01

Factors Figure 2. The HFACS framework. 3 practiced and seemingly automatic behaviors is that they are particularly susceptible to attention and/or memory...been included in most error frameworks, the third and final error form, perceptual errors, has received comparatively less attention . No less...operate safely. After all, just as not everyone can play linebacker for their favorite professional football team or be a concert pianist , not

[Effect of Mn(II) on the error-prone DNA polymerase iota activity in extracts from human normal and tumor cells].

PubMed

Lakhin, A V; Efremova, A S; Makarova, I V; Grishina, E E; Shram, S I; Tarantul, V Z; Gening, L V

2013-01-01

The DNA polymerase iota (Pol iota), which has some peculiar features and is characterized by an extremely error-prone DNA synthesis, belongs to the group of enzymes preferentially activated by Mn2+ instead of Mg2+. In this work, the effect of Mn2+ on DNA synthesis in cell extracts from a) normal human and murine tissues, b) human tumor (uveal melanoma), and c) cultured human tumor cell lines SKOV-3 and HL-60 was tested. Each group displayed characteristic features of Mn-dependent DNA synthesis. The changes in the Mn-dependent DNA synthesis caused by malignant transformation of normal tissues are described. It was also shown that the error-prone DNA synthesis catalyzed by Pol iota in extracts of all cell types was efficiently suppressed by an RNA aptamer (IKL5) against Pol iota obtained in our work earlier. The obtained results suggest that IKL5 might be used to suppress the enhanced activity of Pol iota in tumor cells.

Experimental methods to validate measures of emotional state and readiness for duty in critical operations.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Weston, Louise Marie

2007-09-01

A recent report on criticality accidents in nuclear facilities indicates that human error played a major role in a significant number of incidents with serious consequences and that some of these human errors may be related to the emotional state of the individual. A pre-shift test to detect a deleterious emotional state could reduce the occurrence of such errors in critical operations. The effectiveness of pre-shift testing is a challenge because of the need to gather predictive data in a relatively short test period and the potential occurrence of learning effects due to a requirement for frequent testing. This reportmore » reviews the different types of reliability and validity methods and testing and statistical analysis procedures to validate measures of emotional state. The ultimate value of a validation study depends upon the percentage of human errors in critical operations that are due to the emotional state of the individual. A review of the literature to identify the most promising predictors of emotional state for this application is highly recommended.« less

Multi-muscle FES force control of the human arm for arbitrary goals.

PubMed

Schearer, Eric M; Liao, Yu-Wei; Perreault, Eric J; Tresch, Matthew C; Memberg, William D; Kirsch, Robert F; Lynch, Kevin M

2014-05-01

We present a method for controlling a neuroprosthesis for a paralyzed human arm using functional electrical stimulation (FES) and characterize the errors of the controller. The subject has surgically implanted electrodes for stimulating muscles in her shoulder and arm. Using input/output data, a model mapping muscle stimulations to isometric endpoint forces measured at the subject's hand was identified. We inverted the model of this redundant and coupled multiple-input multiple-output system by minimizing muscle activations and used this inverse for feedforward control. The magnitude of the total root mean square error over a grid in the volume of achievable isometric endpoint force targets was 11% of the total range of achievable forces. Major sources of error were random error due to trial-to-trial variability and model bias due to nonstationary system properties. Because the muscles working collectively are the actuators of the skeletal system, the quantification of errors in force control guides designs of motion controllers for multi-joint, multi-muscle FES systems that can achieve arbitrary goals.

The current approach to human error and blame in the NHS.

PubMed

Ottewill, Melanie

There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.

Cognitive errors: thinking clearly when it could be child maltreatment.

PubMed

Laskey, Antoinette L

2014-10-01

Cognitive errors have been studied in a broad array of fields, including medicine. The more that is understood about how the human mind processes complex information, the more it becomes clear that certain situations are particularly susceptible to less than optimal outcomes because of these errors. This article explores how some of the known cognitive errors may influence the diagnosis of child abuse, resulting in both false-negative and false-positive diagnoses. Suggested remedies for these errors are offered. Copyright © 2014 Elsevier Inc. All rights reserved.

Does the A-not-B error in adult pet dogs indicate sensitivity to human communication?

PubMed

Kis, Anna; Topál, József; Gácsi, Márta; Range, Friederike; Huber, Ludwig; Miklósi, Adám; Virányi, Zsófia

2012-07-01

Recent dog-infant comparisons have indicated that the experimenter's communicative signals in object hide-and-search tasks increase the probability of perseverative (A-not-B) errors in both species (Topál et al. 2009). These behaviourally similar results, however, might reflect different mechanisms in dogs and in children. Similar errors may occur if the motor response of retrieving the object during the A trials cannot be inhibited in the B trials or if the experimenter's movements and signals toward the A hiding place in the B trials ('sham-baiting') distract the dogs' attention. In order to test these hypotheses, we tested dogs similarly to Topál et al. (2009) but eliminated the motor search in the A trials and 'sham-baiting' in the B trials. We found that neither an inability to inhibit previously rewarded motor response nor insufficiencies in their working memory and/or attention skills can explain dogs' erroneous choices. Further, we replicated the finding that dogs have a strong tendency to commit the A-not-B error after ostensive-communicative hiding and demonstrated the crucial effect of socio-communicative cues as the A-not-B error diminishes when location B is ostensively enhanced. These findings further support the hypothesis that the dogs' A-not-B error may reflect a special sensitivity to human communicative cues. Such object-hiding and search tasks provide a typical case for how susceptibility to human social signals could (mis)lead domestic dogs.

Systematic Evaluation of Wajima Superposition (Steady-State Concentration to Mean Residence Time) in the Estimation of Human Intravenous Pharmacokinetic Profile.

PubMed

Lombardo, Franco; Berellini, Giuliano; Labonte, Laura R; Liang, Guiqing; Kim, Sean

2016-03-01

We present a systematic evaluation of the Wajima superpositioning method to estimate the human intravenous (i.v.) pharmacokinetic (PK) profile based on a set of 54 marketed drugs with diverse structure and range of physicochemical properties. We illustrate the use of average of "best methods" for the prediction of clearance (CL) and volume of distribution at steady state (VDss) as described in our earlier work (Lombardo F, Waters NJ, Argikar UA, et al. J Clin Pharmacol. 2013;53(2):178-191; Lombardo F, Waters NJ, Argikar UA, et al. J Clin Pharmacol. 2013;53(2):167-177). These methods provided much more accurate prediction of human PK parameters, yielding 88% and 70% of the prediction within 2-fold error for VDss and CL, respectively. The prediction of human i.v. profile using Wajima superpositioning of rat, dog, and monkey time-concentration profiles was tested against the observed human i.v. PK using fold error statistics. The results showed that 63% of the compounds yielded a geometric mean of fold error below 2-fold, and an additional 19% yielded a geometric mean of fold error between 2- and 3-fold, leaving only 18% of the compounds with a relatively poor prediction. Our results showed that good superposition was observed in any case, demonstrating the predictive value of the Wajima approach, and that the cause of poor prediction of human i.v. profile was mainly due to the poorly predicted CL value, while VDss prediction had a minor impact on the accuracy of human i.v. profile prediction. Copyright © 2016. Published by Elsevier Inc.

Error rates in forensic DNA analysis: definition, numbers, impact and communication.

PubMed

Kloosterman, Ate; Sjerps, Marjan; Quak, Astrid

2014-09-01

Forensic DNA casework is currently regarded as one of the most important types of forensic evidence, and important decisions in intelligence and justice are based on it. However, errors occasionally occur and may have very serious consequences. In other domains, error rates have been defined and published. The forensic domain is lagging behind concerning this transparency for various reasons. In this paper we provide definitions and observed frequencies for different types of errors at the Human Biological Traces Department of the Netherlands Forensic Institute (NFI) over the years 2008-2012. Furthermore, we assess their actual and potential impact and describe how the NFI deals with the communication of these numbers to the legal justice system. We conclude that the observed relative frequency of quality failures is comparable to studies from clinical laboratories and genetic testing centres. Furthermore, this frequency is constant over the five-year study period. The most common causes of failures related to the laboratory process were contamination and human error. Most human errors could be corrected, whereas gross contamination in crime samples often resulted in irreversible consequences. Hence this type of contamination is identified as the most significant source of error. Of the known contamination incidents, most were detected by the NFI quality control system before the report was issued to the authorities, and thus did not lead to flawed decisions like false convictions. However in a very limited number of cases crucial errors were detected after the report was issued, sometimes with severe consequences. Many of these errors were made in the post-analytical phase. The error rates reported in this paper are useful for quality improvement and benchmarking, and contribute to an open research culture that promotes public trust. However, they are irrelevant in the context of a particular case. Here case-specific probabilities of undetected errors are needed. These should be reported, separately from the match probability, when requested by the court or when there are internal or external indications for error. It should also be made clear that there are various other issues to consider, like DNA transfer. Forensic statistical models, in particular Bayesian networks, may be useful to take the various uncertainties into account and demonstrate their effects on the evidential value of the forensic DNA results. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Human-robot cooperative movement training: learning a novel sensory motor transformation during walking with robotic assistance-as-needed.

PubMed

Emken, Jeremy L; Benitez, Raul; Reinkensmeyer, David J

2007-03-28

A prevailing paradigm of physical rehabilitation following neurologic injury is to "assist-as-needed" in completing desired movements. Several research groups are attempting to automate this principle with robotic movement training devices and patient cooperative algorithms that encourage voluntary participation. These attempts are currently not based on computational models of motor learning. Here we assume that motor recovery from a neurologic injury can be modelled as a process of learning a novel sensory motor transformation, which allows us to study a simplified experimental protocol amenable to mathematical description. Specifically, we use a robotic force field paradigm to impose a virtual impairment on the left leg of unimpaired subjects walking on a treadmill. We then derive an "assist-as-needed" robotic training algorithm to help subjects overcome the virtual impairment and walk normally. The problem is posed as an optimization of performance error and robotic assistance. The optimal robotic movement trainer becomes an error-based controller with a forgetting factor that bounds kinematic errors while systematically reducing its assistance when those errors are small. As humans have a natural range of movement variability, we introduce an error weighting function that causes the robotic trainer to disregard this variability. We experimentally validated the controller with ten unimpaired subjects by demonstrating how it helped the subjects learn the novel sensory motor transformation necessary to counteract the virtual impairment, while also preventing them from experiencing large kinematic errors. The addition of the error weighting function allowed the robot assistance to fade to zero even though the subjects' movements were variable. We also show that in order to assist-as-needed, the robot must relax its assistance at a rate faster than that of the learning human. The assist-as-needed algorithm proposed here can limit error during the learning of a dynamic motor task. The algorithm encourages learning by decreasing its assistance as a function of the ongoing progression of movement error. This type of algorithm is well suited for helping people learn dynamic tasks for which large kinematic errors are dangerous or discouraging, and thus may prove useful for robot-assisted movement training of walking or reaching following neurologic injury.

Previous Estimates of Mitochondrial DNA Mutation Level Variance Did Not Account for Sampling Error: Comparing the mtDNA Genetic Bottleneck in Mice and Humans

PubMed Central

Wonnapinij, Passorn; Chinnery, Patrick F.; Samuels, David C.

2010-01-01

In cases of inherited pathogenic mitochondrial DNA (mtDNA) mutations, a mother and her offspring generally have large and seemingly random differences in the amount of mutated mtDNA that they carry. Comparisons of measured mtDNA mutation level variance values have become an important issue in determining the mechanisms that cause these large random shifts in mutation level. These variance measurements have been made with samples of quite modest size, which should be a source of concern because higher-order statistics, such as variance, are poorly estimated from small sample sizes. We have developed an analysis of the standard error of variance from a sample of size n, and we have defined error bars for variance measurements based on this standard error. We calculate variance error bars for several published sets of measurements of mtDNA mutation level variance and show how the addition of the error bars alters the interpretation of these experimental results. We compare variance measurements from human clinical data and from mouse models and show that the mutation level variance is clearly higher in the human data than it is in the mouse models at both the primary oocyte and offspring stages of inheritance. We discuss how the standard error of variance can be used in the design of experiments measuring mtDNA mutation level variance. Our results show that variance measurements based on fewer than 20 measurements are generally unreliable and ideally more than 50 measurements are required to reliably compare variances with less than a 2-fold difference. PMID:20362273

New paradigm for understanding in-flight decision making errors: a neurophysiological model leveraging human factors.

PubMed

Souvestre, P A; Landrock, C K; Blaber, A P

2008-08-01

Human factors centered aviation accident analyses report that skill based errors are known to be cause of 80% of all accidents, decision making related errors 30% and perceptual errors 6%1. In-flight decision making error is a long time recognized major avenue leading to incidents and accidents. Through the past three decades, tremendous and costly efforts have been developed to attempt to clarify causation, roles and responsibility as well as to elaborate various preventative and curative countermeasures blending state of the art biomedical, technological advances and psychophysiological training strategies. In-flight related statistics have not been shown significantly changed and a significant number of issues remain not yet resolved. Fine Postural System and its corollary, Postural Deficiency Syndrome (PDS), both defined in the 1980's, are respectively neurophysiological and medical diagnostic models that reflect central neural sensory-motor and cognitive controls regulatory status. They are successfully used in complex neurotraumatology and related rehabilitation for over two decades. Analysis of clinical data taken over a ten-year period from acute and chronic post-traumatic PDS patients shows a strong correlation between symptoms commonly exhibited before, along side, or even after error, and sensory-motor or PDS related symptoms. Examples are given on how PDS related central sensory-motor control dysfunction can be correctly identified and monitored via a neurophysiological ocular-vestibular-postural monitoring system. The data presented provides strong evidence that a specific biomedical assessment methodology can lead to a better understanding of in-flight adaptive neurophysiological, cognitive and perceptual dysfunctional status that could induce in flight-errors. How relevant human factors can be identified and leveraged to maintain optimal performance will be addressed.

Development and validation of Aviation Causal Contributors for Error Reporting Systems (ACCERS).

PubMed

Baker, David P; Krokos, Kelley J

2007-04-01

This investigation sought to develop a reliable and valid classification system for identifying and classifying the underlying causes of pilot errors reported under the Aviation Safety Action Program (ASAP). ASAP is a voluntary safety program that air carriers may establish to study pilot and crew performance on the line. In ASAP programs, similar to the Aviation Safety Reporting System, pilots self-report incidents by filing a short text description of the event. The identification of contributors to errors is critical if organizations are to improve human performance, yet it is difficult for analysts to extract this information from text narratives. A taxonomy was needed that could be used by pilots to classify the causes of errors. After completing a thorough literature review, pilot interviews and a card-sorting task were conducted in Studies 1 and 2 to develop the initial structure of the Aviation Causal Contributors for Event Reporting Systems (ACCERS) taxonomy. The reliability and utility of ACCERS was then tested in studies 3a and 3b by having pilots independently classify the primary and secondary causes of ASAP reports. The results provided initial evidence for the internal and external validity of ACCERS. Pilots were found to demonstrate adequate levels of agreement with respect to their category classifications. ACCERS appears to be a useful system for studying human error captured under pilot ASAP reports. Future work should focus on how ACCERS is organized and whether it can be used or modified to classify human error in ASAP programs for other aviation-related job categories such as dispatchers. Potential applications of this research include systems in which individuals self-report errors and that attempt to extract and classify the causes of those events.

Systematic analysis of video data from different human–robot interaction studies: a categorization of social signals during error situations

PubMed Central

Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred

2015-01-01

Human–robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human–robot interaction experiments. For that, we analyzed 201 videos of five human–robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human–robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies. PMID:26217266

Neural Correlates of User-initiated Motor Success and Failure - A Brain-Computer Interface Perspective.

PubMed

Yazmir, Boris; Reiner, Miriam

2018-05-15

Any motor action is, by nature, potentially accompanied by human errors. In order to facilitate development of error-tailored Brain-Computer Interface (BCI) correction systems, we focused on internal, human-initiated errors, and investigated EEG correlates of user outcome successes and errors during a continuous 3D virtual tennis game against a computer player. We used a multisensory, 3D, highly immersive environment. Missing and repelling the tennis ball were considered, as 'error' (miss) and 'success' (repel). Unlike most previous studies, where the environment "encouraged" the participant to perform a mistake, here errors happened naturally, resulting from motor-perceptual-cognitive processes of incorrect estimation of the ball kinematics, and can be regarded as user internal, self-initiated errors. Results show distinct and well-defined Event-Related Potentials (ERPs), embedded in the ongoing EEG, that differ across conditions by waveforms, scalp signal distribution maps, source estimation results (sLORETA) and time-frequency patterns, establishing a series of typical features that allow valid discrimination between user internal outcome success and error. The significant delay in latency between positive peaks of error- and success-related ERPs, suggests a cross-talk between top-down and bottom-up processing, represented by an outcome recognition process, in the context of the game world. Success-related ERPs had a central scalp distribution, while error-related ERPs were centro-parietal. The unique characteristics and sharp differences between EEG correlates of error/success provide the crucial components for an improved BCI system. The features of the EEG waveform can be used to detect user action outcome, to be fed into the BCI correction system. Copyright © 2016 IBRO. Published by Elsevier Ltd. All rights reserved.

Injection Molding Parameters Calculations by Using Visual Basic (VB) Programming

NASA Astrophysics Data System (ADS)

Tony, B. Jain A. R.; Karthikeyen, S.; Alex, B. Jeslin A. R.; Hasan, Z. Jahid Ali

2018-03-01

Now a day’s manufacturing industry plays a vital role in production sectors. To fabricate a component lot of design calculation has to be done. There is a chance of human errors occurs during design calculations. The aim of this project is to create a special module using visual basic (VB) programming to calculate injection molding parameters to avoid human errors. To create an injection mold for a spur gear component the following parameters have to be calculated such as Cooling Capacity, Cooling Channel Diameter, and Cooling Channel Length, Runner Length and Runner Diameter, Gate Diameter and Gate Pressure. To calculate the above injection molding parameters a separate module has been created using Visual Basic (VB) Programming to reduce the human errors. The outcome of the module dimensions is the injection molding components such as mold cavity and core design, ejector plate design.

Human error mitigation initiative (HEMI) : summary report.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Stevens, Susan M.; Ramos, M. Victoria; Wenner, Caren A.

2004-11-01

Despite continuing efforts to apply existing hazard analysis methods and comply with requirements, human errors persist across the nuclear weapons complex. Due to a number of factors, current retroactive and proactive methods to understand and minimize human error are highly subjective, inconsistent in numerous dimensions, and are cumbersome to characterize as thorough. An alternative and proposed method begins with leveraging historical data to understand what the systemic issues are and where resources need to be brought to bear proactively to minimize the risk of future occurrences. An illustrative analysis was performed using existing incident databases specific to Pantex weapons operationsmore » indicating systemic issues associated with operating procedures that undergo notably less development rigor relative to other task elements such as tooling and process flow. Future recommended steps to improve the objectivity, consistency, and thoroughness of hazard analysis and mitigation were delineated.« less

Risk assessment of component failure modes and human errors using a new FMECA approach: application in the safety analysis of HDR brachytherapy.

PubMed

Giardina, M; Castiglia, F; Tomarchio, E

2014-12-01

Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events.

Operator performance-enhancing technologies to improve safety. A US DOT safety initiative for meeting the human-centered systems challenge.

DOT National Transportation Integrated Search

1999-11-01

The program implements DOT Human Factors Coordinating Committee (HFCC) recommendations for a coordinated Departmental Human Factors Research Program to advance the human-centered systems approach for enhancing transportation safety. Human error is a ...

The ethics and practical importance of defining, distinguishing and disclosing nursing errors: a discussion paper.

PubMed

Johnstone, Megan-Jane; Kanitsaki, Olga

2006-03-01

Nurses globally are required and expected to report nursing errors. As is clearly demonstrated in the international literature, fulfilling this requirement is not, however, without risks. In this discussion paper, the notion of 'nursing error', the practical and moral importance of defining, distinguishing and disclosing nursing errors and how a distinct definition of 'nursing error' fits with the new 'system approach' to human-error management in health care are critiqued. Drawing on international literature and two key case exemplars from the USA and Australia, arguments are advanced to support the view that although it is 'right' for nurses to report nursing errors, it will be very difficult for them to do so unless a non-punitive approach to nursing-error management is adopted.

The error in total error reduction.

PubMed

Witnauer, James E; Urcelay, Gonzalo P; Miller, Ralph R

2014-02-01

Most models of human and animal learning assume that learning is proportional to the discrepancy between a delivered outcome and the outcome predicted by all cues present during that trial (i.e., total error across a stimulus compound). This total error reduction (TER) view has been implemented in connectionist and artificial neural network models to describe the conditions under which weights between units change. Electrophysiological work has revealed that the activity of dopamine neurons is correlated with the total error signal in models of reward learning. Similar neural mechanisms presumably support fear conditioning, human contingency learning, and other types of learning. Using a computational modeling approach, we compared several TER models of associative learning to an alternative model that rejects the TER assumption in favor of local error reduction (LER), which assumes that learning about each cue is proportional to the discrepancy between the delivered outcome and the outcome predicted by that specific cue on that trial. The LER model provided a better fit to the reviewed data than the TER models. Given the superiority of the LER model with the present data sets, acceptance of TER should be tempered. Copyright © 2013 Elsevier Inc. All rights reserved.

Clinical decision-making: heuristics and cognitive biases for the ophthalmologist.

PubMed

Hussain, Ahsen; Oestreicher, James

Diagnostic errors have a significant impact on health care outcomes and patient care. The underlying causes and development of diagnostic error are complex with flaws in health care systems, as well as human error, playing a role. Cognitive biases and a failure of decision-making shortcuts (heuristics) are human factors that can compromise the diagnostic process. We describe these mechanisms, their role with the clinician, and provide clinical scenarios to highlight the various points at which biases may emerge. We discuss strategies to modify the development and influence of these processes and the vulnerability of heuristics to provide insight and improve clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Meiotic Divisions: No Place for Gender Equality.

PubMed

El Yakoubi, Warif; Wassmann, Katja

2017-01-01

In multicellular organisms the fusion of two gametes with a haploid set of chromosomes leads to the formation of the zygote, the first cell of the embryo. Accurate execution of the meiotic cell division to generate a female and a male gamete is required for the generation of healthy offspring harboring the correct number of chromosomes. Unfortunately, meiosis is error prone. This has severe consequences for fertility and under certain circumstances, health of the offspring. In humans, female meiosis is extremely error prone. In this chapter we will compare male and female meiosis in humans to illustrate why and at which frequency errors occur, and describe how this affects pregnancy outcome and health of the individual. We will first introduce key notions of cell division in meiosis and how they differ from mitosis, followed by a detailed description of the events that are prone to errors during the meiotic divisions.

[Relations between health information systems and patient safety].

PubMed

Nøhr, Christian

2012-11-05

Health information systems have the potential to reduce medical errors, and indeed many studies have shown a significant reduction. However, if the systems are not designed and implemented properly, there is evidence that suggest that new types of errors will arise--i.e., technology-induced errors. Health information systems will need to undergo a more rigorous evaluation. Usability evaluation and simulation test with humans in the loop can help to detect and prevent technology-induced errors before they are deployed in real health-care settings.

Anatomy of an incident

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.

A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less

Anatomy of an incident

DOE PAGES

Cournoyer, Michael E.; Trujillo, Stanley; Lawton, Cindy M.; ...

2016-03-23

A traditional view of incidents is that they are caused by shortcomings in human competence, attention, or attitude. It may be under the label of “loss of situational awareness,” procedure “violation,” or “poor” management. A different view is that human error is not the cause of failure, but a symptom of failure – trouble deeper inside the system. In this perspective, human error is not the conclusion, but rather the starting point of investigations. During an investigation, three types of information are gathered: physical, documentary, and human (recall/experience). Through the causal analysis process, apparent cause or apparent causes are identifiedmore » as the most probable cause or causes of an incident or condition that management has the control to fix and for which effective recommendations for corrective actions can be generated. A causal analysis identifies relevant human performance factors. In the following presentation, the anatomy of a radiological incident is discussed, and one case study is presented. We analyzed the contributing factors that caused a radiological incident. When underlying conditions, decisions, actions, and inactions that contribute to the incident are identified. This includes weaknesses that may warrant improvements that tolerate error. Measures that reduce consequences or likelihood of recurrence are discussed.« less

Application of manual control theory to the study of biological stress

NASA Technical Reports Server (NTRS)

Replogle, C. R.; Holden, F. M.; Iay, C. N.

1972-01-01

A study was run using both a stable, third-order task and an adaptive first-order unstable task singly and in combination to test the effects of 2 min hypoxia (22000 ft) on human operator. The results indicate that the RMS error in the stable task does not change as a function of hypoxic stress whereas the error in an unstable task changes significantly. Models involving human operator parameter changes and noise injection are discussed.

21st Century Human Performance.

ERIC Educational Resources Information Center

Clark, Ruth Colvin

1995-01-01

Technology can extend human memory and improve performance, but bypassing human intelligence has its dangers. Cognitive apprenticeships that compress learning experiences, provide coaching, and allow trial and error can build complex problem-solving skills and develop expertise. (SK)

Target Uncertainty Mediates Sensorimotor Error Correction

PubMed Central

Vijayakumar, Sethu; Wolpert, Daniel M.

2017-01-01

Human movements are prone to errors that arise from inaccuracies in both our perceptual processing and execution of motor commands. We can reduce such errors by both improving our estimates of the state of the world and through online error correction of the ongoing action. Two prominent frameworks that explain how humans solve these problems are Bayesian estimation and stochastic optimal feedback control. Here we examine the interaction between estimation and control by asking if uncertainty in estimates affects how subjects correct for errors that may arise during the movement. Unbeknownst to participants, we randomly shifted the visual feedback of their finger position as they reached to indicate the center of mass of an object. Even though participants were given ample time to compensate for this perturbation, they only fully corrected for the induced error on trials with low uncertainty about center of mass, with correction only partial in trials involving more uncertainty. The analysis of subjects’ scores revealed that participants corrected for errors just enough to avoid significant decrease in their overall scores, in agreement with the minimal intervention principle of optimal feedback control. We explain this behavior with a term in the loss function that accounts for the additional effort of adjusting one’s response. By suggesting that subjects’ decision uncertainty, as reflected in their posterior distribution, is a major factor in determining how their sensorimotor system responds to error, our findings support theoretical models in which the decision making and control processes are fully integrated. PMID:28129323

Target Uncertainty Mediates Sensorimotor Error Correction.

PubMed

Acerbi, Luigi; Vijayakumar, Sethu; Wolpert, Daniel M

2017-01-01

Human movements are prone to errors that arise from inaccuracies in both our perceptual processing and execution of motor commands. We can reduce such errors by both improving our estimates of the state of the world and through online error correction of the ongoing action. Two prominent frameworks that explain how humans solve these problems are Bayesian estimation and stochastic optimal feedback control. Here we examine the interaction between estimation and control by asking if uncertainty in estimates affects how subjects correct for errors that may arise during the movement. Unbeknownst to participants, we randomly shifted the visual feedback of their finger position as they reached to indicate the center of mass of an object. Even though participants were given ample time to compensate for this perturbation, they only fully corrected for the induced error on trials with low uncertainty about center of mass, with correction only partial in trials involving more uncertainty. The analysis of subjects' scores revealed that participants corrected for errors just enough to avoid significant decrease in their overall scores, in agreement with the minimal intervention principle of optimal feedback control. We explain this behavior with a term in the loss function that accounts for the additional effort of adjusting one's response. By suggesting that subjects' decision uncertainty, as reflected in their posterior distribution, is a major factor in determining how their sensorimotor system responds to error, our findings support theoretical models in which the decision making and control processes are fully integrated.

Human error in hospitals and industrial accidents: current concepts.

PubMed

Spencer, F C

2000-10-01

Most data concerning errors and accidents are from industrial accidents and airline injuries. General Electric, Alcoa, and Motorola, among others, all have reported complex programs that resulted in a marked reduction in frequency of worker injuries. In the field of medicine, however, with the outstanding exception of anesthesiology, there is a paucity of information, most reports referring to the 1984 Harvard-New York State Study, more than 16 years ago. This scarcity of information indicates the complexity of the problem. It seems very unlikely that simple exhortation or additional regulations will help because the problem lies principally in the multiple human-machine interfaces that constitute modern medical care. The absence of success stories also indicates that the best methods have to be learned by experience. A liaison with industry should be helpful, although the varieties of human illness are far different from a standardized manufacturing process. Concurrent with the studies of industrial and nuclear accidents, cognitive psychologists have intensively studied how the brain stores and retrieves information. Several concepts have emerged. First, errors are not character defects to be treated by the classic approach of discipline and education, but are byproducts of normal thinking that occur frequently. Second, major accidents are rarely causedby a single error; instead, they are often a combination of chronic system errors, termed latent errors. Identifying and correcting these latent errors should be the principal focus for corrective planning rather than searching for an individual culprit. This nonpunitive concept of errors is a key basis for an effective reporting system, brilliantly demonstrated in aviation with the ASRS system developed more than 25 years ago. The ASRS currently receives more than 30,000 reports annually and is credited with the remarkable increase in safety of airplane travel. Adverse drug events constitute about 25% of hospital errors. In the future, the combination of new drugs and a vast amount of new information will additionally increase the possibilities for error. Two major advances in recent years have been computerization and active participation of the pharmacist with dispensing medications. Further investigation of hospital errors should concentrate primarily on latent system errors. Significant system changes will require broad staff participation throughout the hospital. This, in turn, should foster development of an institutional safety culture, rather than the popular attitude that patient safety responsibility is concentrated in the Quality Assurance-Risk Management division. Quality of service and patient safety are closely intertwined.

Risk of Performance and Behavioral Health Decrements Due to Inadequate Cooperation, Coordination, Communication, and Psychosocial Adaptation within a Team

NASA Technical Reports Server (NTRS)

Landon, Lauren Blackwell; Vessey, William B.; Barrett, Jamie D.

2015-01-01

A team is defined as: "two or more individuals who interact socially and adaptively, have shared or common goals, and hold meaningful task interdependences; it is hierarchically structured and has a limited life span; in it expertise and roles are distributed; and it is embedded within an organization/environmental context that influences and is influenced by ongoing processes and performance outcomes" (Salas, Stagl, Burke, & Goodwin, 2007, p. 189). From the NASA perspective, a team is commonly understood to be a collection of individuals that is assigned to support and achieve a particular mission. Thus, depending on context, this definition can encompass both the spaceflight crew and the individuals and teams in the larger multi-team system who are assigned to support that crew during a mission. The Team Risk outcomes of interest are predominantly performance related, with a secondary emphasis on long-term health; this is somewhat unique in the NASA HRP in that most Risk areas are medically related and primarily focused on long-term health consequences. In many operational environments (e.g., aviation), performance is assessed as the avoidance of errors. However, the research on performance errors is ambiguous. It implies that actions may be dichotomized into "correct" or "incorrect" responses, where incorrect responses or errors are always undesirable. Researchers have argued that this dichotomy is a harmful oversimplification, and it would be more productive to focus on the variability of human performance and how organizations can manage that variability (Hollnagel, Woods, & Leveson, 2006) (Category III1). Two problems occur when focusing on performance errors: 1) the errors are infrequent and, therefore, difficult to observe and record; and 2) the errors do not directly correspond to failure. Research reveals that humans are fairly adept at correcting or compensating for performance errors before such errors result in recognizable or recordable failures. Astronauts are notably adept high performers. Most failures are recorded only when multiple, small errors occur and humans are unable to recognize and correct or compensate for these errors in time to prevent a failure (Dismukes, Berman, Loukopoulos, 2007) (Category III). More commonly, observers record variability in levels of performance. Some teams commit no observable errors but fail to achieve performance objectives or perform only adequately, while other teams commit some errors but perform spectacularly. Successful performance, therefore, cannot be viewed as simply the absence of errors or the avoidance of failure Johnson Space Center (JSC) Joint Leadership Team, 2008). While failure is commonly attributed to making a major error, focusing solely on the elimination of error(s) does not significantly reduce the risk of failure. Failure may also occur when performance is simply insufficient or an effort is incapable of adjusting sufficiently to a contextual change (e.g., changing levels of autonomy).

Human factors and the FDA's goals: improved medical device design.

PubMed

Burlington, D B

1996-01-01

The Food and Drug Administration's new human factors design requirements for medical devices were previewed by the director of the FDA's Center for Devices and Radiological Health (CDRH) at AAMI/FDA's Human Factors in Medical Devices Conference held in September 1995. Director Bruce Burlington, MD, said the FDA plans to take a closer look at how new medical devices are designed to ensure proper attention has been paid to human error prevention. As a medical practitioner who has witnessed use-related deaths and injuries, Burlington stressed the importance of the medical community's reporting use errors as they occur and manufacturers' creating easy-to-use labeling and packaging. He also called for simplicity and quality of design in medical products, and asked for a consolidated effort of all professionals involved in human factors issues to help implement and further the FDA's new human factors program. An edited version of his presentation appears here.

IRBs, conflict and liability: will we see IRBs in court? Or is it when?

PubMed

Icenogle, Daniel L

2003-01-01

The entire human research infrastructure is under intense and increasing financial pressure. These pressures may have been responsible for several errors in judgment by those responsible for managing human research and protecting human subjects. The result of these errors has been some terrible accidents, some of which have cost the lives of human research volunteers. This, in turn, is producing both increased liability risk for those who manage the various aspects of human research and increasing scrutiny as to the capability of the human research protection structure as currently constituted. It is the author's contention that the current structure is fully capable of offering sufficient protection for participants in human research-if Institutional Review Board (IRB) staff and members are given sufficient resources and perform their tasks with sufficient responsibility. The status quo alternative is that IRBs and their members will find themselves at great risk of becoming defendants in lawsuits seeking compensation for damages resulting from human experimentation gone awry.

Optical Fiber Connection Navigation System Using Visible Light Communication in Central Office with Economic Evaluation

NASA Astrophysics Data System (ADS)

Waki, Masaki; Uruno, Shigenori; Ohashi, Hiroyuki; Manabe, Tetsuya; Azuma, Yuji

We propose an optical fiber connection navigation system that uses visible light communication for an integrated distribution module in a central office. The system realizes an accurate database, requires less skilled work to operate and eliminates human error. This system can achieve a working time reduction of up to 88.0% compared with the conventional work without human error for the connection/removal of optical fiber cords, and is economical as regards installation and operation.

Classification and reduction of pilot error

NASA Technical Reports Server (NTRS)

Rogers, W. H.; Logan, A. L.; Boley, G. D.

1989-01-01

Human error is a primary or contributing factor in about two-thirds of commercial aviation accidents worldwide. With the ultimate goal of reducing pilot error accidents, this contract effort is aimed at understanding the factors underlying error events and reducing the probability of certain types of errors by modifying underlying factors such as flight deck design and procedures. A review of the literature relevant to error classification was conducted. Classification includes categorizing types of errors, the information processing mechanisms and factors underlying them, and identifying factor-mechanism-error relationships. The classification scheme developed by Jens Rasmussen was adopted because it provided a comprehensive yet basic error classification shell or structure that could easily accommodate addition of details on domain-specific factors. For these purposes, factors specific to the aviation environment were incorporated. Hypotheses concerning the relationship of a small number of underlying factors, information processing mechanisms, and error types types identified in the classification scheme were formulated. ASRS data were reviewed and a simulation experiment was performed to evaluate and quantify the hypotheses.

Human-robot cooperative movement training: Learning a novel sensory motor transformation during walking with robotic assistance-as-needed

PubMed Central

Emken, Jeremy L; Benitez, Raul; Reinkensmeyer, David J

2007-01-01

Background A prevailing paradigm of physical rehabilitation following neurologic injury is to "assist-as-needed" in completing desired movements. Several research groups are attempting to automate this principle with robotic movement training devices and patient cooperative algorithms that encourage voluntary participation. These attempts are currently not based on computational models of motor learning. Methods Here we assume that motor recovery from a neurologic injury can be modelled as a process of learning a novel sensory motor transformation, which allows us to study a simplified experimental protocol amenable to mathematical description. Specifically, we use a robotic force field paradigm to impose a virtual impairment on the left leg of unimpaired subjects walking on a treadmill. We then derive an "assist-as-needed" robotic training algorithm to help subjects overcome the virtual impairment and walk normally. The problem is posed as an optimization of performance error and robotic assistance. The optimal robotic movement trainer becomes an error-based controller with a forgetting factor that bounds kinematic errors while systematically reducing its assistance when those errors are small. As humans have a natural range of movement variability, we introduce an error weighting function that causes the robotic trainer to disregard this variability. Results We experimentally validated the controller with ten unimpaired subjects by demonstrating how it helped the subjects learn the novel sensory motor transformation necessary to counteract the virtual impairment, while also preventing them from experiencing large kinematic errors. The addition of the error weighting function allowed the robot assistance to fade to zero even though the subjects' movements were variable. We also show that in order to assist-as-needed, the robot must relax its assistance at a rate faster than that of the learning human. Conclusion The assist-as-needed algorithm proposed here can limit error during the learning of a dynamic motor task. The algorithm encourages learning by decreasing its assistance as a function of the ongoing progression of movement error. This type of algorithm is well suited for helping people learn dynamic tasks for which large kinematic errors are dangerous or discouraging, and thus may prove useful for robot-assisted movement training of walking or reaching following neurologic injury. PMID:17391527

Are "Human Factors" the Primary Cause of Complications in the Field of Implant Dentistry?

PubMed

Renouard, Franck; Amalberti, René; Renouard, Erell

Complications in medicine and dentistry are usually analyzed from a purely technical point of view. Rarely is the role of human behavior or judgment considered as a reason for adverse outcomes. When the role of human factors is considered, these are usually described in general terms rather than specifically identifying the factors responsible for an adverse event. The impact of cognitive and behavioral factors in the explanation of adverse events has been studied in other high-stakes areas such as aviation and nuclear power. Specific protocols have been developed to reduce rates of human error, and, where human error is unavoidable, to lessen its impact. This approach has dramatically reduced the incidence of accidents in these fields. This article aims to review how a similar approach may prove valuable in the reduction of complications in implant dentistry.

Errors Recruit both Cognitive and Emotional Monitoring Systems: Simultaneous Intracranial Recordings in the Dorsal Anterior Cingulate Gyrus and Amygdala Combined with fMRI

ERIC Educational Resources Information Center

Pourtois, Gilles; Vocat, Roland; N'Diaye, Karim; Spinelli, Laurent; Seeck, Margitta; Vuilleumier, Patrik

2010-01-01

We studied error monitoring in a human patient with unique implantation of depth electrodes in both the left dorsal cingulate gyrus and medial temporal lobe prior to surgery. The patient performed a speeded go/nogo task and made a substantial number of commission errors (false alarms). As predicted, intracranial Local Field Potentials (iLFPs) in…

Performance Monitoring Applied to System Supervision

PubMed Central

Somon, Bertille; Campagne, Aurélie; Delorme, Arnaud; Berberian, Bruno

2017-01-01

Nowadays, automation is present in every aspect of our daily life and has some benefits. Nonetheless, empirical data suggest that traditional automation has many negative performance and safety consequences as it changed task performers into task supervisors. In this context, we propose to use recent insights into the anatomical and neurophysiological substrates of action monitoring in humans, to help further characterize performance monitoring during system supervision. Error monitoring is critical for humans to learn from the consequences of their actions. A wide variety of studies have shown that the error monitoring system is involved not only in our own errors, but also in the errors of others. We hypothesize that the neurobiological correlates of the self-performance monitoring activity can be applied to system supervision. At a larger scale, a better understanding of system supervision may allow its negative effects to be anticipated or even countered. This review is divided into three main parts. First, we assess the neurophysiological correlates of self-performance monitoring and their characteristics during error execution. Then, we extend these results to include performance monitoring and error observation of others or of systems. Finally, we provide further directions in the study of system supervision and assess the limits preventing us from studying a well-known phenomenon: the Out-Of-the-Loop (OOL) performance problem. PMID:28744209

Study of style effects on OCR errors in the MEDLINE database

NASA Astrophysics Data System (ADS)

Garrison, Penny; Davis, Diane L.; Andersen, Tim L.; Barney Smith, Elisa H.

2005-01-01

The National Library of Medicine has developed a system for the automatic extraction of data from scanned journal articles to populate the MEDLINE database. Although the 5-engine OCR system used in this process exhibits good performance overall, it does make errors in character recognition that must be corrected in order for the process to achieve the requisite accuracy. The correction process works by feeding words that have characters with less than 100% confidence (as determined automatically by the OCR engine) to a human operator who then must manually verify the word or correct the error. The majority of these errors are contained in the affiliation information zone where the characters are in italics or small fonts. Therefore only affiliation information data is used in this research. This paper examines the correlation between OCR errors and various character attributes in the MEDLINE database, such as font size, italics, bold, etc. and OCR confidence levels. The motivation for this research is that if a correlation between the character style and types of errors exists it should be possible to use this information to improve operator productivity by increasing the probability that the correct word option is presented to the human editor. We have determined that this correlation exists, in particular for the case of characters with diacritics.

The Control of Behavior: Human and Environmental

ERIC Educational Resources Information Center

Burhoe, Ralph Wendell

1972-01-01

Theological perspective on human and environmental behavior, with a view toward man's ultimate concerns or longest range values and the ultimate controls of behavior. Maintains that all human behavior and destiny is ultimately in the hand of a transcendent power which prevails over any human errors.'' (LK)

Stereoscopic distance perception

NASA Technical Reports Server (NTRS)

Foley, John M.

1989-01-01

Limited cue, open-loop tasks in which a human observer indicates distances or relations among distances are discussed. By open-loop tasks, it is meant tasks in which the observer gets no feedback as to the accuracy of the responses. What happens when cues are added and when the loop is closed are considered. The implications of this research for the effectiveness of visual displays is discussed. Errors in visual distance tasks do not necessarily mean that the percept is in error. The error could arise in transformations that intervene between the percept and the response. It is argued that the percept is in error. It is also argued that there exist post-perceptual transformations that may contribute to the error or be modified by feedback to correct for the error.

A new method for the assessment of patient safety competencies during a medical school clerkship using an objective structured clinical examination

PubMed Central

Daud-Gallotti, Renata Mahfuz; Morinaga, Christian Valle; Arlindo-Rodrigues, Marcelo; Velasco, Irineu Tadeu; Arruda Martins, Milton; Tiberio, Iolanda Calvo

2011-01-01

INTRODUCTION: Patient safety is seldom assessed using objective evaluations during undergraduate medical education. OBJECTIVE: To evaluate the performance of fifth-year medical students using an objective structured clinical examination focused on patient safety after implementation of an interactive program based on adverse events recognition and disclosure. METHODS: In 2007, a patient safety program was implemented in the internal medicine clerkship of our hospital. The program focused on human error theory, epidemiology of incidents, adverse events, and disclosure. Upon completion of the program, students completed an objective structured clinical examination with five stations and standardized patients. One station focused on patient safety issues, including medical error recognition/disclosure, the patient-physician relationship and humanism issues. A standardized checklist was completed by each standardized patient to assess the performance of each student. The student's global performance at each station and performance in the domains of medical error, the patient-physician relationship and humanism were determined. The correlations between the student performances in these three domains were calculated. RESULTS: A total of 95 students participated in the objective structured clinical examination. The mean global score at the patient safety station was 87.59±1.24 points. Students' performance in the medical error domain was significantly lower than their performance on patient-physician relationship and humanistic issues. Less than 60% of students (n = 54) offered the simulated patient an apology after a medical error occurred. A significant correlation was found between scores obtained in the medical error domains and scores related to both the patient-physician relationship and humanistic domains. CONCLUSIONS: An objective structured clinical examination is a useful tool to evaluate patient safety competencies during the medical student clerkship. PMID:21876976

Exponential error reduction in pretransfusion testing with automation.

PubMed

South, Susan F; Casina, Tony S; Li, Lily

2012-08-01

Protecting the safety of blood transfusion is the top priority of transfusion service laboratories. Pretransfusion testing is a critical element of the entire transfusion process to enhance vein-to-vein safety. Human error associated with manual pretransfusion testing is a cause of transfusion-related mortality and morbidity and most human errors can be eliminated by automated systems. However, the uptake of automation in transfusion services has been slow and many transfusion service laboratories around the world still use manual blood group and antibody screen (G&S) methods. The goal of this study was to compare error potentials of commonly used manual (e.g., tiles and tubes) versus automated (e.g., ID-GelStation and AutoVue Innova) G&S methods. Routine G&S processes in seven transfusion service laboratories (four with manual and three with automated G&S methods) were analyzed using failure modes and effects analysis to evaluate the corresponding error potentials of each method. Manual methods contained a higher number of process steps ranging from 22 to 39, while automated G&S methods only contained six to eight steps. Corresponding to the number of the process steps that required human interactions, the risk priority number (RPN) of the manual methods ranged from 5304 to 10,976. In contrast, the RPN of the automated methods was between 129 and 436 and also demonstrated a 90% to 98% reduction of the defect opportunities in routine G&S testing. This study provided quantitative evidence on how automation could transform pretransfusion testing processes by dramatically reducing error potentials and thus would improve the safety of blood transfusion. © 2012 American Association of Blood Banks.

Cognitive decision errors and organization vulnerabilities in nuclear power plant safety management: Modeling using the TOGA meta-theory framework

DOE Office of Scientific and Technical Information (OSTI.GOV)

Cappelli, M.; Gadomski, A. M.; Sepiellis, M.

In the field of nuclear power plant (NPP) safety modeling, the perception of the role of socio-cognitive engineering (SCE) is continuously increasing. Today, the focus is especially on the identification of human and organization decisional errors caused by operators and managers under high-risk conditions, as evident by analyzing reports on nuclear incidents occurred in the past. At present, the engineering and social safety requirements need to enlarge their domain of interest in such a way to include all possible losses generating events that could be the consequences of an abnormal state of a NPP. Socio-cognitive modeling of Integrated Nuclear Safetymore » Management (INSM) using the TOGA meta-theory has been discussed during the ICCAP 2011 Conference. In this paper, more detailed aspects of the cognitive decision-making and its possible human errors and organizational vulnerability are presented. The formal TOGA-based network model for cognitive decision-making enables to indicate and analyze nodes and arcs in which plant operators and managers errors may appear. The TOGA's multi-level IPK (Information, Preferences, Knowledge) model of abstract intelligent agents (AIAs) is applied. In the NPP context, super-safety approach is also discussed, by taking under consideration unexpected events and managing them from a systemic perspective. As the nature of human errors depends on the specific properties of the decision-maker and the decisional context of operation, a classification of decision-making using IPK is suggested. Several types of initial situations of decision-making useful for the diagnosis of NPP operators and managers errors are considered. The developed models can be used as a basis for applications to NPP educational or engineering simulators to be used for training the NPP executive staff. (authors)« less

Design and Validation of an Infrared Badal Optometer for Laser Speckle (IBOLS)

PubMed Central

Teel, Danielle F. W.; Copland, R. James; Jacobs, Robert J.; Wells, Thad; Neal, Daniel R.; Thibos, Larry N.

2009-01-01

Purpose To validate the design of an infrared wavefront aberrometer with a Badal optometer employing the principle of laser speckle generated by a spinning disk and infrared light. The instrument was designed for subjective meridional refraction in infrared light by human patients. Methods Validation employed a model eye with known refractive error determined with an objective infrared wavefront aberrometer. The model eye was used to produce a speckle pattern on an artificial retina with controlled amounts of ametropia introduced with auxiliary ophthalmic lenses. A human observer performed the psychophysical task of observing the speckle pattern (with the aid of a video camera sensitive to infrared radiation) formed on the artificial retina. Refraction was performed by adjusting the vergence of incident light with the Badal optometer to nullify the motion of laser speckle. Validation of the method was performed for different levels of spherical ametropia and for various configurations of an astigmatic model eye. Results Subjective measurements of meridional refractive error over the range −4D to + 4D agreed with astigmatic refractive errors predicted by the power of the model eye in the meridian of motion of the spinning disk. Conclusions Use of a Badal optometer to control laser speckle is a valid method for determining subjective refractive error at infrared wavelengths. Such an instrument will be useful for comparing objective measures of refractive error obtained for the human eye with autorefractors and wavefront aberrometers that employ infrared radiation. PMID:18772719

Safe prescribing: a titanic challenge

PubMed Central

Routledge, Philip A

2012-01-01

The challenge to achieve safe prescribing merits the adjective ‘titanic’. The organisational and human errors leading to poor prescribing (e.g. underprescribing, overprescribing, misprescribing or medication errors) have parallels in the organisational and human errors that led to the loss of the Titanic 100 years ago this year. Prescribing can be adversely affected by communication failures, critical conditions, complacency, corner cutting, callowness and a lack of courage of conviction, all of which were also factors leading to the Titanic tragedy. These issues need to be addressed by a commitment to excellence, the final component of the ‘Seven C's’. Optimal prescribing is dependent upon close communication and collaborative working between highly trained health professionals, whose role is to ensure maximum clinical effectiveness, whilst also protecting their patients from avoidable harm. Since humans are prone to error, and the environments in which they work are imperfect, it is not surprising that medication errors are common, occurring more often during the prescribing stage than during dispensing or administration. A commitment to excellence in prescribing includes a continued focus on lifelong learning (including interprofessional learning) in pharmacology and therapeutics. This should be accompanied by improvements in the clinical working environment of prescribers, and the encouragement of a strong safety culture (including reporting of adverse incidents as well as suspected adverse drug reactions whenever appropriate). Finally, members of the clinical team must be prepared to challenge each other, when necessary, to ensure that prescribing combines the highest likelihood of benefit with the lowest potential for harm. PMID:22738396

Development of a new calibration procedure and its experimental validation applied to a human motion capture system.

PubMed

Royo Sánchez, Ana Cristina; Aguilar Martín, Juan José; Santolaria Mazo, Jorge

2014-12-01

Motion capture systems are often used for checking and analyzing human motion in biomechanical applications. It is important, in this context, that the systems provide the best possible accuracy. Among existing capture systems, optical systems are those with the highest accuracy. In this paper, the development of a new calibration procedure for optical human motion capture systems is presented. The performance and effectiveness of that new calibration procedure are also checked by experimental validation. The new calibration procedure consists of two stages. In the first stage, initial estimators of intrinsic and extrinsic parameters are sought. The camera calibration method used in this stage is the one proposed by Tsai. These parameters are determined from the camera characteristics, the spatial position of the camera, and the center of the capture volume. In the second stage, a simultaneous nonlinear optimization of all parameters is performed to identify the optimal values, which minimize the objective function. The objective function, in this case, minimizes two errors. The first error is the distance error between two markers placed in a wand. The second error is the error of position and orientation of the retroreflective markers of a static calibration object. The real co-ordinates of the two objects are calibrated in a co-ordinate measuring machine (CMM). The OrthoBio system is used to validate the new calibration procedure. Results are 90% lower than those from the previous calibration software and broadly comparable with results from a similarly configured Vicon system.

Model-based influences on humans' choices and striatal prediction errors.

PubMed

Daw, Nathaniel D; Gershman, Samuel J; Seymour, Ben; Dayan, Peter; Dolan, Raymond J

2011-03-24

The mesostriatal dopamine system is prominently implicated in model-free reinforcement learning, with fMRI BOLD signals in ventral striatum notably covarying with model-free prediction errors. However, latent learning and devaluation studies show that behavior also shows hallmarks of model-based planning, and the interaction between model-based and model-free values, prediction errors, and preferences is underexplored. We designed a multistep decision task in which model-based and model-free influences on human choice behavior could be distinguished. By showing that choices reflected both influences we could then test the purity of the ventral striatal BOLD signal as a model-free report. Contrary to expectations, the signal reflected both model-free and model-based predictions in proportions matching those that best explained choice behavior. These results challenge the notion of a separate model-free learner and suggest a more integrated computational architecture for high-level human decision-making. Copyright © 2011 Elsevier Inc. All rights reserved.

Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review.

PubMed

Patel, Santosh; Loveridge, Robert

2015-12-01

Drug administration errors in obstetric neuraxial anesthesia can have devastating consequences. Although fully recognizing that they represent "only the tip of the iceberg," published case reports/series of these errors were reviewed in detail with the aim of estimating the frequency and the nature of these errors. We identified case reports and case series from MEDLINE and performed a quantitative analysis of the involved drugs, error setting, source of error, the observed complications, and any therapeutic interventions. We subsequently performed a qualitative analysis of the human factors involved and proposed modifications to practice. Twenty-nine cases were identified. Various drugs were given in error, but no direct effects on the course of labor, mode of delivery, or neonatal outcome were reported. Four maternal deaths from the accidental intrathecal administration of tranexamic acid were reported, all occurring after delivery of the fetus. A range of hemodynamic and neurologic signs and symptoms were noted, but the most commonly reported complication was the failure of the intended neuraxial anesthetic technique. Several human factors were present; most common factors were drug storage issues and similar drug appearance. Four practice recommendations were identified as being likely to have prevented the errors. The reported errors exposed latent conditions within health care systems. We suggest that the implementation of the following processes may decrease the risk of these types of drug errors: (1) Careful reading of the label on any drug ampule or syringe before the drug is drawn up or injected; (2) labeling all syringes; (3) checking labels with a second person or a device (such as a barcode reader linked to a computer) before the drug is drawn up or administered; and (4) use of non-Luer lock connectors on all epidural/spinal/combined spinal-epidural devices. Further study is required to determine whether routine use of these processes will reduce drug error.

Human Factors in Financial Trading: An Analysis of Trading Incidents.

PubMed

Leaver, Meghan; Reader, Tom W

2016-09-01

This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors-related issues in operational trading incidents. In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors-related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. © 2016, Human Factors and Ergonomics Society.

Dopamine reward prediction error coding.

PubMed

Schultz, Wolfram

2016-03-01

Reward prediction errors consist of the differences between received and predicted rewards. They are crucial for basic forms of learning about rewards and make us strive for more rewards-an evolutionary beneficial trait. Most dopamine neurons in the midbrain of humans, monkeys, and rodents signal a reward prediction error; they are activated by more reward than predicted (positive prediction error), remain at baseline activity for fully predicted rewards, and show depressed activity with less reward than predicted (negative prediction error). The dopamine signal increases nonlinearly with reward value and codes formal economic utility. Drugs of addiction generate, hijack, and amplify the dopamine reward signal and induce exaggerated, uncontrolled dopamine effects on neuronal plasticity. The striatum, amygdala, and frontal cortex also show reward prediction error coding, but only in subpopulations of neurons. Thus, the important concept of reward prediction errors is implemented in neuronal hardware.

Dopamine reward prediction error coding

PubMed Central

Schultz, Wolfram

2016-01-01

Reward prediction errors consist of the differences between received and predicted rewards. They are crucial for basic forms of learning about rewards and make us strive for more rewards—an evolutionary beneficial trait. Most dopamine neurons in the midbrain of humans, monkeys, and rodents signal a reward prediction error; they are activated by more reward than predicted (positive prediction error), remain at baseline activity for fully predicted rewards, and show depressed activity with less reward than predicted (negative prediction error). The dopamine signal increases nonlinearly with reward value and codes formal economic utility. Drugs of addiction generate, hijack, and amplify the dopamine reward signal and induce exaggerated, uncontrolled dopamine effects on neuronal plasticity. The striatum, amygdala, and frontal cortex also show reward prediction error coding, but only in subpopulations of neurons. Thus, the important concept of reward prediction errors is implemented in neuronal hardware. PMID:27069377

Five Papers on Human-Machine Interaction.

ERIC Educational Resources Information Center

Norman, Donald A.

Different aspects of human-machine interaction are discussed in the five brief papers that comprise this report. The first paper, "Some Observations on Mental Models," discusses the role of a person's mental model in the interaction with systems. The second paper, "A Psychologist Views Human Processing: Human Errors and Other…

Subsecond dopamine fluctuations in human striatum encode superposed error signals about actual and counterfactual reward

PubMed Central

Kishida, Kenneth T.; Saez, Ignacio; Lohrenz, Terry; Witcher, Mark R.; Laxton, Adrian W.; Tatter, Stephen B.; White, Jason P.; Ellis, Thomas L.; Phillips, Paul E. M.; Montague, P. Read

2016-01-01

In the mammalian brain, dopamine is a critical neuromodulator whose actions underlie learning, decision-making, and behavioral control. Degeneration of dopamine neurons causes Parkinson’s disease, whereas dysregulation of dopamine signaling is believed to contribute to psychiatric conditions such as schizophrenia, addiction, and depression. Experiments in animal models suggest the hypothesis that dopamine release in human striatum encodes reward prediction errors (RPEs) (the difference between actual and expected outcomes) during ongoing decision-making. Blood oxygen level-dependent (BOLD) imaging experiments in humans support the idea that RPEs are tracked in the striatum; however, BOLD measurements cannot be used to infer the action of any one specific neurotransmitter. We monitored dopamine levels with subsecond temporal resolution in humans (n = 17) with Parkinson’s disease while they executed a sequential decision-making task. Participants placed bets and experienced monetary gains or losses. Dopamine fluctuations in the striatum fail to encode RPEs, as anticipated by a large body of work in model organisms. Instead, subsecond dopamine fluctuations encode an integration of RPEs with counterfactual prediction errors, the latter defined by how much better or worse the experienced outcome could have been. How dopamine fluctuations combine the actual and counterfactual is unknown. One possibility is that this process is the normal behavior of reward processing dopamine neurons, which previously had not been tested by experiments in animal models. Alternatively, this superposition of error terms may result from an additional yet-to-be-identified subclass of dopamine neurons. PMID:26598677

Subsecond dopamine fluctuations in human striatum encode superposed error signals about actual and counterfactual reward.

PubMed

Kishida, Kenneth T; Saez, Ignacio; Lohrenz, Terry; Witcher, Mark R; Laxton, Adrian W; Tatter, Stephen B; White, Jason P; Ellis, Thomas L; Phillips, Paul E M; Montague, P Read

2016-01-05

In the mammalian brain, dopamine is a critical neuromodulator whose actions underlie learning, decision-making, and behavioral control. Degeneration of dopamine neurons causes Parkinson's disease, whereas dysregulation of dopamine signaling is believed to contribute to psychiatric conditions such as schizophrenia, addiction, and depression. Experiments in animal models suggest the hypothesis that dopamine release in human striatum encodes reward prediction errors (RPEs) (the difference between actual and expected outcomes) during ongoing decision-making. Blood oxygen level-dependent (BOLD) imaging experiments in humans support the idea that RPEs are tracked in the striatum; however, BOLD measurements cannot be used to infer the action of any one specific neurotransmitter. We monitored dopamine levels with subsecond temporal resolution in humans (n = 17) with Parkinson's disease while they executed a sequential decision-making task. Participants placed bets and experienced monetary gains or losses. Dopamine fluctuations in the striatum fail to encode RPEs, as anticipated by a large body of work in model organisms. Instead, subsecond dopamine fluctuations encode an integration of RPEs with counterfactual prediction errors, the latter defined by how much better or worse the experienced outcome could have been. How dopamine fluctuations combine the actual and counterfactual is unknown. One possibility is that this process is the normal behavior of reward processing dopamine neurons, which previously had not been tested by experiments in animal models. Alternatively, this superposition of error terms may result from an additional yet-to-be-identified subclass of dopamine neurons.

Increased instrument intelligence--can it reduce laboratory error?

PubMed

Jekelis, Albert W

2005-01-01

Recent literature has focused on the reduction of laboratory errors and the potential impact on patient management. This study assessed the intelligent, automated preanalytical process-control abilities in newer generation analyzers as compared with older analyzers and the impact on error reduction. Three generations of immuno-chemistry analyzers were challenged with pooled human serum samples for a 3-week period. One of the three analyzers had an intelligent process of fluidics checks, including bubble detection. Bubbles can cause erroneous results due to incomplete sample aspiration. This variable was chosen because it is the most easily controlled sample defect that can be introduced. Traditionally, lab technicians have had to visually inspect each sample for the presence of bubbles. This is time consuming and introduces the possibility of human error. Instruments with bubble detection may be able to eliminate the human factor and reduce errors associated with the presence of bubbles. Specific samples were vortexed daily to introduce a visible quantity of bubbles, then immediately placed in the daily run. Errors were defined as a reported result greater than three standard deviations below the mean and associated with incomplete sample aspiration of the analyte of the individual analyzer Three standard deviations represented the target limits of proficiency testing. The results of the assays were examined for accuracy and precision. Efficiency, measured as process throughput, was also measured to associate a cost factor and potential impact of the error detection on the overall process. The analyzer performance stratified according to their level of internal process control The older analyzers without bubble detection reported 23 erred results. The newest analyzer with bubble detection reported one specimen incorrectly. The precision and accuracy of the nonvortexed specimens were excellent and acceptable for all three analyzers. No errors were found in the nonvortexed specimens. There were no significant differences in overall process time for any of the analyzers when tests were arranged in an optimal configuration. The analyzer with advanced fluidic intelligence demostrated the greatest ability to appropriately deal with an incomplete aspiration by not processing and reporting a result for the sample. This study suggests that preanalytical process-control capabilities could reduce errors. By association, it implies that similar intelligent process controls could favorably impact the error rate and, in the case of this instrument, do it without negatively impacting process throughput. Other improvements may be realized as a result of having an intelligent error-detection process including further reduction in misreported results, fewer repeats, less operator intervention, and less reagent waste.

A system dynamic simulation model for managing the human error in power tools industries

NASA Astrophysics Data System (ADS)

Jamil, Jastini Mohd; Shaharanee, Izwan Nizal Mohd

2017-10-01

In the era of modern and competitive life of today, every organization will face the situations in which the work does not proceed as planned when there is problems occur in which it had to be delay. However, human error is often cited as the culprit. The error that made by the employees would cause them have to spend additional time to identify and check for the error which in turn could affect the normal operations of the company as well as the company's reputation. Employee is a key element of the organization in running all of the activities of organization. Hence, work performance of the employees is a crucial factor in organizational success. The purpose of this study is to identify the factors that cause the increasing errors make by employees in the organization by using system dynamics approach. The broadly defined targets in this study are employees in the Regional Material Field team from purchasing department in power tools industries. Questionnaires were distributed to the respondents to obtain their perceptions on the root cause of errors make by employees in the company. The system dynamics model was developed to simulate the factor of the increasing errors make by employees and its impact. The findings of this study showed that the increasing of error make by employees was generally caused by the factors of workload, work capacity, job stress, motivation and performance of employees. However, this problem could be solve by increased the number of employees in the organization.

Identifying types and causes of errors in mortality data in a clinical registry using multiple information systems.

PubMed

Koetsier, Antonie; Peek, Niels; de Keizer, Nicolette

2012-01-01

Errors may occur in the registration of in-hospital mortality, making it less reliable as a quality indicator. We assessed the types of errors made in in-hospital mortality registration in the clinical quality registry National Intensive Care Evaluation (NICE) by comparing its mortality data to data from a national insurance claims database. Subsequently, we performed site visits at eleven Intensive Care Units (ICUs) to investigate the number, types and causes of errors made in in-hospital mortality registration. A total of 255 errors were found in the NICE registry. Two different types of software malfunction accounted for almost 80% of the errors. The remaining 20% were five types of manual transcription errors and human failures to record outcome data. Clinical registries should be aware of the possible existence of errors in recorded outcome data and understand their causes. In order to prevent errors, we recommend to thoroughly verify the software that is used in the registration process.

The SACADA database for human reliability and human performance

DOE Office of Scientific and Technical Information (OSTI.GOV)

Y. James Chang; Dennis Bley; Lawrence Criscione

2014-05-01

Lack of appropriate and sufficient human performance data has been identified as a key factor affecting human reliability analysis (HRA) quality especially in the estimation of human error probability (HEP). The Scenario Authoring, Characterization, and Debriefing Application (SACADA) database was developed by the U.S. Nuclear Regulatory Commission (NRC) to address this data need. An agreement between NRC and the South Texas Project Nuclear Operating Company (STPNOC) was established to support the SACADA development with aims to make the SACADA tool suitable for implementation in the nuclear power plants' operator training program to collect operator performance information. The collected data wouldmore » support the STPNOC's operator training program and be shared with the NRC for improving HRA quality. This paper discusses the SACADA data taxonomy, the theoretical foundation, the prospective data to be generated from the SACADA raw data to inform human reliability and human performance, and the considerations on the use of simulator data for HRA. Each SACADA data point consists of two information segments: context and performance results. Context is a characterization of the performance challenges to task success. The performance results are the results of performing the task. The data taxonomy uses a macrocognitive functions model for the framework. At a high level, information is classified according to the macrocognitive functions of detecting the plant abnormality, understanding the abnormality, deciding the response plan, executing the response plan, and team related aspects (i.e., communication, teamwork, and supervision). The data are expected to be useful for analyzing the relations between context, error modes and error causes in human performance.« less

Human Factors for More Usable and Safer Health Information Technology: Where Are We Now and Where do We Go from Here?

PubMed

Kushniruk, A; Nohr, C; Borycki, E

2016-11-10

A wide range of human factors approaches have been developed and adapted to healthcare for detecting and mitigating negative unexpected consequences associated with technology in healthcare (i.e. technology-induced errors). However, greater knowledge and wider dissemination of human factors methods is needed to ensure more usable and safer health information technology (IT) systems. This paper reports on work done by the IMIA Human Factors Working Group and discusses some successful approaches that have been applied in using human factors to mitigate negative unintended consequences of health IT. The paper addresses challenges in bringing human factors approaches into mainstream health IT development. A framework for bringing human factors into the improvement of health IT is described that involves a multi-layered systematic approach to detecting technology-induced errors at all stages of a IT system development life cycle (SDLC). Such an approach has been shown to be needed and can lead to reduced risks associated with the release of health IT systems into live use with mitigation of risks of negative unintended consequences. Negative unintended consequences of the introduction of IT into healthcare (i.e. potential for technology-induced errors) continue to be reported. It is concluded that methods and approaches from the human factors and usability engineering literatures need to be more widely applied, both in the vendor community and in local and regional hospital and healthcare settings. This will require greater efforts at dissemination and knowledge translation, as well as greater interaction between the academic and vendor communities.

Evidence Report: Risk of Performance Errors Due to Training Deficiencies

NASA Technical Reports Server (NTRS)

Barshi, Immanuel

2012-01-01

The Risk of Performance Errors Due to Training Deficiencies is identified by the National Aeronautics and Space Administration (NASA) Human Research Program (HRP) as a recognized risk to human health and performance in space. The HRP Program Requirements Document (PRD) defines these risks. This Evidence Report provides a summary of the evidence that has been used to identify and characterize this risk. Given that training content, timing, intervals, and delivery methods must support crew task performance, and given that training paradigms will be different for long-duration missions with increased crew autonomy, there is a risk that operators will lack the skills or knowledge necessary to complete critical tasks, resulting in flight and ground crew errors and inefficiencies, failed mission and program objectives, and an increase in crew injuries.

On parameters identification of computational models of vibrations during quiet standing of humans

NASA Astrophysics Data System (ADS)

Barauskas, R.; Krušinskienė, R.

2007-12-01

Vibration of the center of pressure (COP) of human body on the base of support during quiet standing is a very popular clinical research, which provides useful information about the physical and health condition of an individual. In this work, vibrations of COP of a human body in forward-backward direction during still standing are generated using controlled inverted pendulum (CIP) model with a single degree of freedom (dof) supplied with proportional, integral and differential (PID) controller, which represents the behavior of the central neural system of a human body and excited by cumulative disturbance vibration, generated within the body due to breathing or any other physical condition. The identification of the model and disturbance parameters is an important stage while creating a close-to-reality computational model able to evaluate features of disturbance. The aim of this study is to present the CIP model parameters identification approach based on the information captured by time series of the COP signal. The identification procedure is based on an error function minimization. Error function is formulated in terms of time laws of computed and experimentally measured COP vibrations. As an alternative, error function is formulated in terms of the stabilogram diffusion function (SDF). The minimization of error functions is carried out by employing methods based on sensitivity functions of the error with respect to model and excitation parameters. The sensitivity functions are obtained by using the variational techniques. The inverse dynamic problem approach has been employed in order to establish the properties of the disturbance time laws ensuring the satisfactory coincidence of measured and computed COP vibration laws. The main difficulty of the investigated problem is encountered during the model validation stage. Generally, neither the PID controller parameter set nor the disturbance time law are known in advance. In this work, an error function formulated in terms of time derivative of disturbance torque has been proposed in order to obtain PID controller parameters, as well as the reference time law of the disturbance. The disturbance torque is calculated from experimental data using the inverse dynamic approach. Experiments presented in this study revealed that vibrations of disturbance torque and PID controller parameters identified by the method may be qualified as feasible in humans. Presented approach may be easily extended to structural models with any number of dof or higher structural complexity.

Evaluation of lens distortion errors using an underwater camera system for video-based motion analysis

NASA Technical Reports Server (NTRS)

Poliner, Jeffrey; Fletcher, Lauren; Klute, Glenn K.

1994-01-01

Video-based motion analysis systems are widely employed to study human movement, using computers to capture, store, process, and analyze video data. This data can be collected in any environment where cameras can be located. One of the NASA facilities where human performance research is conducted is the Weightless Environment Training Facility (WETF), a pool of water which simulates zero-gravity with neutral buoyance. Underwater video collection in the WETF poses some unique problems. This project evaluates the error caused by the lens distortion of the WETF cameras. A grid of points of known dimensions was constructed and videotaped using a video vault underwater system. Recorded images were played back on a VCR and a personal computer grabbed and stored the images on disk. These images were then digitized to give calculated coordinates for the grid points. Errors were calculated as the distance from the known coordinates of the points to the calculated coordinates. It was demonstrated that errors from lens distortion could be as high as 8 percent. By avoiding the outermost regions of a wide-angle lens, the error can be kept smaller.

Managerial process improvement: a lean approach to eliminating medication delivery.

PubMed

Hussain, Aftab; Stewart, LaShonda M; Rivers, Patrick A; Munchus, George

2015-01-01

Statistical evidence shows that medication errors are a major cause of injuries that concerns all health care oganizations. Despite all the efforts to improve the quality of care, the lack of understanding and inability of management to design a robust system that will strategically target those factors is a major cause of distress. The paper aims to discuss these issues. Achieving optimum organizational performance requires two key variables; work process factors and human performance factors. The approach is that healthcare administrators must take in account both variables in designing a strategy to reduce medication errors. However, strategies that will combat such phenomena require that managers and administrators understand the key factors that are causing medication delivery errors. The authors recommend that healthcare organizations implement the Toyota Production System (TPS) combined with human performance improvement (HPI) methodologies to eliminate medication delivery errors in hospitals. Despite all the efforts to improve the quality of care, there continues to be a lack of understanding and the ability of management to design a robust system that will strategically target those factors associated with medication errors. This paper proposes a solution to an ambiguous workflow process using the TPS combined with the HPI system.

Fourier decomposition of spatial localization errors reveals an idiotropic dominance of an internal model of gravity.

PubMed

De Sá Teixeira, Nuno Alexandre

2014-12-01

Given its conspicuous nature, gravity has been acknowledged by several research lines as a prime factor in structuring the spatial perception of one's environment. One such line of enquiry has focused on errors in spatial localization aimed at the vanishing location of moving objects - it has been systematically reported that humans mislocalize spatial positions forward, in the direction of motion (representational momentum) and downward in the direction of gravity (representational gravity). Moreover, spatial localization errors were found to evolve dynamically with time in a pattern congruent with an anticipated trajectory (representational trajectory). The present study attempts to ascertain the degree to which vestibular information plays a role in these phenomena. Human observers performed a spatial localization task while tilted to varying degrees and referring to the vanishing locations of targets moving along several directions. A Fourier decomposition of the obtained spatial localization errors revealed that although spatial errors were increased "downward" mainly along the body's longitudinal axis (idiotropic dominance), the degree of misalignment between the latter and physical gravity modulated the time course of the localization responses. This pattern is surmised to reflect increased uncertainty about the internal model when faced with conflicting cues regarding the perceived "downward" direction.

Psychological Effects of Technological/Human-Caused Environmental Disasters: Examination of the Navajo and Uranium

ERIC Educational Resources Information Center

Markstrom, Carol A.; Charley, Perry H.

2003-01-01

Disasters can be defined as catastrophic events that challenge the normal range of human coping ability. The technological/human-caused disaster, a classification of interest in this article, is attributable to human error or misjudgment. Lower socioeconomic status and race intersect in the heightened risk for technological/human-caused disasters…

Application of objective clinical human reliability analysis (OCHRA) in assessment of technical performance in laparoscopic rectal cancer surgery.

PubMed

Foster, J D; Miskovic, D; Allison, A S; Conti, J A; Ockrim, J; Cooper, E J; Hanna, G B; Francis, N K

2016-06-01

Laparoscopic rectal resection is technically challenging, with outcomes dependent upon technical performance. No robust objective assessment tool exists for laparoscopic rectal resection surgery. This study aimed to investigate the application of the objective clinical human reliability analysis (OCHRA) technique for assessing technical performance of laparoscopic rectal surgery and explore the validity and reliability of this technique. Laparoscopic rectal cancer resection operations were described in the format of a hierarchical task analysis. Potential technical errors were defined. The OCHRA technique was used to identify technical errors enacted in videos of twenty consecutive laparoscopic rectal cancer resection operations from a single site. The procedural task, spatial location, and circumstances of all identified errors were logged. Clinical validity was assessed through correlation with clinical outcomes; reliability was assessed by test-retest. A total of 335 execution errors identified, with a median 15 per operation. More errors were observed during pelvic tasks compared with abdominal tasks (p < 0.001). Within the pelvis, more errors were observed during dissection on the right side than the left (p = 0.03). Test-retest confirmed reliability (r = 0.97, p < 0.001). A significant correlation was observed between error frequency and mesorectal specimen quality (r s = 0.52, p = 0.02) and with blood loss (r s = 0.609, p = 0.004). OCHRA offers a valid and reliable method for evaluating technical performance of laparoscopic rectal surgery.

An MEG signature corresponding to an axiomatic model of reward prediction error.

PubMed

Talmi, Deborah; Fuentemilla, Lluis; Litvak, Vladimir; Duzel, Emrah; Dolan, Raymond J

2012-01-02

Optimal decision-making is guided by evaluating the outcomes of previous decisions. Prediction errors are theoretical teaching signals which integrate two features of an outcome: its inherent value and prior expectation of its occurrence. To uncover the magnetic signature of prediction errors in the human brain we acquired magnetoencephalographic (MEG) data while participants performed a gambling task. Our primary objective was to use formal criteria, based upon an axiomatic model (Caplin and Dean, 2008a), to determine the presence and timing profile of MEG signals that express prediction errors. We report analyses at the sensor level, implemented in SPM8, time locked to outcome onset. We identified, for the first time, a MEG signature of prediction error, which emerged approximately 320 ms after an outcome and expressed as an interaction between outcome valence and probability. This signal followed earlier, separate signals for outcome valence and probability, which emerged approximately 200 ms after an outcome. Strikingly, the time course of the prediction error signal, as well as the early valence signal, resembled the Feedback-Related Negativity (FRN). In simultaneously acquired EEG data we obtained a robust FRN, but the win and loss signals that comprised this difference wave did not comply with the axiomatic model. Our findings motivate an explicit examination of the critical issue of timing embodied in computational models of prediction errors as seen in human electrophysiological data. Copyright © 2011 Elsevier Inc. All rights reserved.

Complacency and Automation Bias in the Use of Imperfect Automation.

PubMed

Wickens, Christopher D; Clegg, Benjamin A; Vieane, Alex Z; Sebok, Angelia L

2015-08-01

We examine the effects of two different kinds of decision-aiding automation errors on human-automation interaction (HAI), occurring at the first failure following repeated exposure to correctly functioning automation. The two errors are incorrect advice, triggering the automation bias, and missing advice, reflecting complacency. Contrasts between analogous automation errors in alerting systems, rather than decision aiding, have revealed that alerting false alarms are more problematic to HAI than alerting misses are. Prior research in decision aiding, although contrasting the two aiding errors (incorrect vs. missing), has confounded error expectancy. Participants performed an environmental process control simulation with and without decision aiding. For those with the aid, automation dependence was created through several trials of perfect aiding performance, and an unexpected automation error was then imposed in which automation was either gone (one group) or wrong (a second group). A control group received no automation support. The correct aid supported faster and more accurate diagnosis and lower workload. The aid failure degraded all three variables, but "automation wrong" had a much greater effect on accuracy, reflecting the automation bias, than did "automation gone," reflecting the impact of complacency. Some complacency was manifested for automation gone, by a longer latency and more modest reduction in accuracy. Automation wrong, creating the automation bias, appears to be a more problematic form of automation error than automation gone, reflecting complacency. Decision-aiding automation should indicate its lower degree of confidence in uncertain environments to avoid the automation bias. © 2015, Human Factors and Ergonomics Society.

Human-simulation-based learning to prevent medication error: A systematic review.

PubMed

Sarfati, Laura; Ranchon, Florence; Vantard, Nicolas; Schwiertz, Vérane; Larbre, Virginie; Parat, Stéphanie; Faudel, Amélie; Rioufol, Catherine

2018-01-31

In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME. A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning. Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance. Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is well designed. © 2018 John Wiley & Sons, Ltd.

Human Factors Process Task Analysis Liquid Oxygen Pump Acceptance Test Procedure for the Advanced Technology Development Center

NASA Technical Reports Server (NTRS)

Diorio, Kimberly A.

2002-01-01

A process task analysis effort was undertaken by Dynacs Inc. commencing in June 2002 under contract from NASA YA-D6. Funding was provided through NASA's Ames Research Center (ARC), Code M/HQ, and Industrial Engineering and Safety (IES). The John F. Kennedy Space Center (KSC) Engineering Development Contract (EDC) Task Order was 5SMA768. The scope of the effort was to conduct a Human Factors Process Failure Modes and Effects Analysis (HF PFMEA) of a hazardous activity and provide recommendations to eliminate or reduce the effects of errors caused by human factors. The Liquid Oxygen (LOX) Pump Acceptance Test Procedure (ATP) was selected for this analysis. The HF PFMEA table (see appendix A) provides an analysis of six major categories evaluated for this study. These categories include Personnel Certification, Test Procedure Format, Test Procedure Safety Controls, Test Article Data, Instrumentation, and Voice Communication. For each specific requirement listed in appendix A, the following topics were addressed: Requirement, Potential Human Error, Performance-Shaping Factors, Potential Effects of the Error, Barriers and Controls, Risk Priority Numbers, and Recommended Actions. This report summarizes findings and gives recommendations as determined by the data contained in appendix A. It also includes a discussion of technology barriers and challenges to performing task analyses, as well as lessons learned. The HF PFMEA table in appendix A recommends the use of accepted and required safety criteria in order to reduce the risk of human error. The items with the highest risk priority numbers should receive the greatest amount of consideration. Implementation of the recommendations will result in a safer operation for all personnel.

Results of a nuclear power plant application of A New Technique for Human Error Analysis (ATHEANA)

DOE Office of Scientific and Technical Information (OSTI.GOV)

Whitehead, D.W.; Forester, J.A.; Bley, D.C.

1998-03-01

A new method to analyze human errors has been demonstrated at a pressurized water reactor (PWR) nuclear power plant. This was the first application of the new method referred to as A Technique for Human Error Analysis (ATHEANA). The main goals of the demonstration were to test the ATHEANA process as described in the frame-of-reference manual and the implementation guideline, test a training package developed for the method, test the hypothesis that plant operators and trainers have significant insight into the error-forcing-contexts (EFCs) that can make unsafe actions (UAs) more likely, and to identify ways to improve the method andmore » its documentation. A set of criteria to evaluate the success of the ATHEANA method as used in the demonstration was identified. A human reliability analysis (HRA) team was formed that consisted of an expert in probabilistic risk assessment (PRA) with some background in HRA (not ATHEANA) and four personnel from the nuclear power plant. Personnel from the plant included two individuals from their PRA staff and two individuals from their training staff. Both individuals from training are currently licensed operators and one of them was a senior reactor operator on shift until a few months before the demonstration. The demonstration was conducted over a 5-month period and was observed by members of the Nuclear Regulatory Commission`s ATHEANA development team, who also served as consultants to the HRA team when necessary. Example results of the demonstration to date, including identified human failure events (HFEs), UAs, and EFCs are discussed. Also addressed is how simulator exercises are used in the ATHEANA demonstration project.« less

Mistake proofing: changing designs to reduce error

PubMed Central

Grout, J R

2006-01-01

Mistake proofing uses changes in the physical design of processes to reduce human error. It can be used to change designs in ways that prevent errors from occurring, to detect errors after they occur but before harm occurs, to allow processes to fail safely, or to alter the work environment to reduce the chance of errors. Effective mistake proofing design changes should initially be effective in reducing harm, be inexpensive, and easily implemented. Over time these design changes should make life easier and speed up the process. Ideally, the design changes should increase patients' and visitors' understanding of the process. These designs should themselves be mistake proofed and follow the good design practices of other disciplines. PMID:17142609

Understanding Risk Tolerance and Building an Effective Safety Culture

NASA Technical Reports Server (NTRS)

Loyd, David

2018-01-01

Estimates range from 65-90 percent of catastrophic mishaps are due to human error. NASA's human factors-related mishaps causes are estimated at approximately 75 percent. As much as we'd like to error-proof our work environment, even the most automated and complex technical endeavors require human interaction... and are vulnerable to human frailty. Industry and government are focusing not only on human factors integration into hazardous work environments, but also looking for practical approaches to cultivating a strong Safety Culture that diminishes risk. Industry and government organizations have recognized the value of monitoring leading indicators to identify potential risk vulnerabilities. NASA has adapted this approach to assess risk controls associated with hazardous, critical, and complex facilities. NASA's facility risk assessments integrate commercial loss control, OSHA (Occupational Safety and Health Administration) Process Safety, API (American Petroleum Institute) Performance Indicator Standard, and NASA Operational Readiness Inspection concepts to identify risk control vulnerabilities.

How To Make the Most of Your Human: Design Considerations for Single Pilot Operations

NASA Technical Reports Server (NTRS)

Schutte, Paul C.

2015-01-01

Reconsidering the function allocation between automation and the pilot in the flight deck is the next step in improving aviation safety. The current allocation, based on who does what best, makes poor use of the pilot's resources and abilities. In some cases it may actually handicap pilots from performing their role. Improving pilot performance first lies in defining the role of the pilot - why a human is needed in the first place. The next step is allocating functions based on the needs of that role (rather than fitness), then using automation to target specific human weaknesses in performing that role. Examples are provided (some of which could be implemented in conventional cockpits now). Along the way, the definition of human error and the idea that eliminating/automating the pilot will reduce instances of human error will be challenged.

Airline Crew Training

NASA Technical Reports Server (NTRS)

1989-01-01

The discovery that human error has caused many more airline crashes than mechanical malfunctions led to an increased emphasis on teamwork and coordination in airline flight training programs. Human factors research at Ames Research Center has produced two crew training programs directed toward more effective operations. Cockpit Resource Management (CRM) defines areas like decision making, workload distribution, communication skills, etc. as essential in addressing human error problems. In 1979, a workshop led to the implementation of the CRM program by United Airlines, and later other airlines. In Line Oriented Flight Training (LOFT), crews fly missions in realistic simulators while instructors induce emergency situations requiring crew coordination. This is followed by a self critique. Ames Research Center continues its involvement with these programs.

"Bed Side" Human Milk Analysis in the Neonatal Intensive Care Unit: A Systematic Review.

PubMed

Fusch, Gerhard; Kwan, Celia; Kotrri, Gynter; Fusch, Christoph

2017-03-01

Human milk analyzers can measure macronutrient content in native breast milk to tailor adequate supplementation with fortifiers. This article reviews all studies using milk analyzers, including (i) evaluation of devices, (ii) the impact of different conditions on the macronutrient analysis of human milk, and (iii) clinical trials to improve growth. Results lack consistency, potentially due to systematic errors in the validation of the device, or pre-analytical sample preparation errors like homogenization. It is crucial to introduce good laboratory and clinical practice when using these devices; otherwise a non-validated clinical usage can severely affect growth outcomes of infants. Copyright © 2016 Elsevier Inc. All rights reserved.

Establishing a culture for patient safety - the role of education.

PubMed

Milligan, Frank J

2007-02-01

This paper argues that the process of making significant moves towards a patient safety culture requires changes in healthcare education. Improvements in patient safety are a shared international priority as too many errors and other forms of unnecessary harm are currently occurring in the process of caring for and treating patients. A description of the patient safety agenda is given followed by a brief analysis of human factors theory and its use in other safety critical industries, most notably aviation. The all too common problem of drug administration errors is used to illustrate the relevance of human factors theory to healthcare education with specific mention made of the Human Factors Analysis and Classification System (HFACS).

45 CFR 60.6 - Reporting errors, omissions, and revisions.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Section 60.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION NATIONAL PRACTITIONER DATA BANK FOR ADVERSE INFORMATION ON PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS Reporting of Information § 60.6 Reporting errors, omissions, and revisions. (a) Persons and entities are responsible for...

Encoder fault analysis system based on Moire fringe error signal

NASA Astrophysics Data System (ADS)

Gao, Xu; Chen, Wei; Wan, Qiu-hua; Lu, Xin-ran; Xie, Chun-yu

2018-02-01

Aiming at the problem of any fault and wrong code in the practical application of photoelectric shaft encoder, a fast and accurate encoder fault analysis system is researched from the aspect of Moire fringe photoelectric signal processing. DSP28335 is selected as the core processor and high speed serial A/D converter acquisition card is used. And temperature measuring circuit using AD7420 is designed. Discrete data of Moire fringe error signal is collected at different temperatures and it is sent to the host computer through wireless transmission. The error signal quality index and fault type is displayed on the host computer based on the error signal identification method. The error signal quality can be used to diagnosis the state of error code through the human-machine interface.

What Is the Epigenome?

MedlinePlus

... to epigenetic errors. Scientists continue to explore the relationship between the genome and the chemical compounds that ... variety of cells to begin to assess the relationship between epigenomics and human disease. Human Epigenome Atlas ...

One Size Does Not Fit All: Human Failure Event Decomposition and Task Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ronald Laurids Boring, PhD

2014-09-01

In the probabilistic safety assessments (PSAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered or exacerbated by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally,more » both approaches should arrive at the same set of HFEs. This question remains central as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PSAs tend to be top-down—defined as a subset of the PSA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) are more likely to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications. In this paper, I first review top-down and bottom-up approaches for defining HFEs and then present a seven-step guideline to ensure a task analysis completed as part of human error identification decomposes to a level suitable for use as HFEs. This guideline illustrates an effective way to bridge the bottom-up approach with top-down requirements.« less

Agreement between Computerized and Human Assessment of Performance on the Ruff Figural Fluency Test

PubMed Central

Elderson, Martin F.; Pham, Sander; van Eersel, Marlise E. A.; Wolffenbuttel, Bruce H. R.; Kok, Johan; Gansevoort, Ron T.; Tucha, Oliver; van der Klauw, Melanie M.; Slaets, Joris P. J.

2016-01-01

The Ruff Figural Fluency Test (RFFT) is a sensitive test for nonverbal fluency suitable for all age groups. However, assessment of performance on the RFFT is time-consuming and may be affected by interrater differences. Therefore, we developed computer software specifically designed to analyze performance on the RFFT by automated pattern recognition. The aim of this study was to compare assessment by the new software with conventional assessment by human raters. The software was developed using data from the Lifelines Cohort Study and validated in an independent cohort of the Prevention of Renal and Vascular End Stage Disease (PREVEND) study. The total study population included 1,761 persons: 54% men; mean age (SD), 58 (10) years. All RFFT protocols were assessed by the new software and two independent human raters (criterion standard). The mean number of unique designs (SD) was 81 (29) and the median number of perseverative errors (interquartile range) was 9 (4 to 16). The intraclass correlation coefficient (ICC) between the computerized and human assessment was 0.994 (95%CI, 0.988 to 0.996; p<0.001) and 0.991 (95%CI, 0.990 to 0.991; p<0.001) for the number of unique designs and perseverative errors, respectively. The mean difference (SD) between the computerized and human assessment was -1.42 (2.78) and +0.02 (1.94) points for the number of unique designs and perseverative errors, respectively. This was comparable to the agreement between two independent human assessments: ICC, 0.995 (0.994 to 0.995; p<0.001) and 0.985 (0.982 to 0.988; p<0.001), and mean difference (SD), -0.44 (2.98) and +0.56 (2.36) points for the number of unique designs and perseverative errors, respectively. We conclude that the agreement between the computerized and human assessment was very high and comparable to the agreement between two independent human assessments. Therefore, the software is an accurate tool for the assessment of performance on the RFFT. PMID:27661083

Blood transfusion sampling and a greater role for error recovery.

PubMed

Oldham, Jane

Patient identification errors in pre-transfusion blood sampling ('wrong blood in tube') are a persistent area of risk. These errors can potentially result in life-threatening complications. Current measures to address root causes of incidents and near misses have not resolved this problem and there is a need to look afresh at this issue. PROJECT PURPOSE: This narrative review of the literature is part of a wider system-improvement project designed to explore and seek a better understanding of the factors that contribute to transfusion sampling error as a prerequisite to examining current and potential approaches to error reduction. A broad search of the literature was undertaken to identify themes relating to this phenomenon. KEY DISCOVERIES: Two key themes emerged from the literature. Firstly, despite multi-faceted causes of error, the consistent element is the ever-present potential for human error. Secondly, current focus on error prevention could potentially be augmented with greater attention to error recovery. Exploring ways in which clinical staff taking samples might learn how to better identify their own errors is proposed to add to current safety initiatives.

Sensitivity to prediction error in reach adaptation

PubMed Central

Haith, Adrian M.; Harran, Michelle D.; Shadmehr, Reza

2012-01-01

It has been proposed that the brain predicts the sensory consequences of a movement and compares it to the actual sensory feedback. When the two differ, an error signal is formed, driving adaptation. How does an error in one trial alter performance in the subsequent trial? Here we show that the sensitivity to error is not constant but declines as a function of error magnitude. That is, one learns relatively less from large errors compared with small errors. We performed an experiment in which humans made reaching movements and randomly experienced an error in both their visual and proprioceptive feedback. Proprioceptive errors were created with force fields, and visual errors were formed by perturbing the cursor trajectory to create a visual error that was smaller, the same size, or larger than the proprioceptive error. We measured single-trial adaptation and calculated sensitivity to error, i.e., the ratio of the trial-to-trial change in motor commands to error size. We found that for both sensory modalities sensitivity decreased with increasing error size. A reanalysis of a number of previously published psychophysical results also exhibited this feature. Finally, we asked how the brain might encode sensitivity to error. We reanalyzed previously published probabilities of cerebellar complex spikes (CSs) and found that this probability declined with increasing error size. From this we posit that a CS may be representative of the sensitivity to error, and not error itself, a hypothesis that may explain conflicting reports about CSs and their relationship to error. PMID:22773782

A Quantum Theoretical Explanation for Probability Judgment Errors

ERIC Educational Resources Information Center

Busemeyer, Jerome R.; Pothos, Emmanuel M.; Franco, Riccardo; Trueblood, Jennifer S.

2011-01-01

A quantum probability model is introduced and used to explain human probability judgment errors including the conjunction and disjunction fallacies, averaging effects, unpacking effects, and order effects on inference. On the one hand, quantum theory is similar to other categorization and memory models of cognition in that it relies on vector…

45 CFR 60.6 - Reporting errors, omissions, and revisions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 1 2010-10-01 2010-10-01 false Reporting errors, omissions, and revisions. 60.6 Section 60.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION NATIONAL PRACTITIONER DATA BANK FOR ADVERSE INFORMATION ON PHYSICIANS AND OTHER HEALTH CARE PRACTITIONERS Reporting of...

A New KE-Free Online ICALL System Featuring Error Contingent Feedback

ERIC Educational Resources Information Center

Tokuda, Naoyuki; Chen, Liang

2004-01-01

As a first step towards implementing a human language teacher, we have developed a new template-based on-line ICALL (intelligent computer assisted language learning) system capable of automatically diagnosing learners' free-format translated inputs and returning error contingent feedback. The system architecture we have adopted allows language…

Minimizing Accidents and Risks in High Adventure Outdoor Pursuits.

ERIC Educational Resources Information Center

Meier, Joel

The fundamental dilemma in adventure programming is eliminating unreasonable risks to participants without also reducing levels of excitement, challenge, and stress. Most accidents are caused by a combination of unsafe conditions, unsafe acts, and error judgments. The best and only way to minimize critical human error in adventure programs is…

Spatial Resolution, Grayscale, and Error Diffusion Trade-offs: Impact on Display System Design

NASA Technical Reports Server (NTRS)

Gille, Jennifer L. (Principal Investigator)

1996-01-01

We examine technology trade-offs related to grayscale resolution, spatial resolution, and error diffusion for tessellated display systems. We present new empirical results from our psychophysical study of these trade-offs and compare them to the predictions of a model of human vision.

Pilots of the future - Human or computer?

NASA Technical Reports Server (NTRS)

Chambers, A. B.; Nagel, D. C.

1985-01-01

In connection with the occurrence of aircraft accidents and the evolution of the air-travel system, questions arise regarding the computer's potential for making fundamental contributions to improving the safety and reliability of air travel. An important result of an analysis of the causes of aircraft accidents is the conclusion that humans - 'pilots and other personnel' - are implicated in well over half of the accidents which occur. Over 70 percent of the incident reports contain evidence of human error. In addition, almost 75 percent show evidence of an 'information-transfer' problem. Thus, the question arises whether improvements in air safety could be achieved by removing humans from control situations. In an attempt to answer this question, it is important to take into account also certain advantages which humans have in comparison to computers. Attention is given to human error and the effects of technology, the motivation to automate, aircraft automation at the crossroads, the evolution of cockpit automation, and pilot factors.

Human dignity and the future of the voluntary active euthanasia debate in South Africa.

PubMed

Jordaan, Donrich W

2017-04-25

The issue of voluntary active euthanasia was thrust into the public policy arena by the Stransham-Ford lawsuit. The High Court legalised voluntary active euthanasia - however, ostensibly only in the specific case of Mr Stransham-Ford. The Supreme Court of Appeal overturned the High Court judgment on technical grounds, not on the merits. This means that in future the courts can be approached again to consider the legalisation of voluntary active euthanasia. As such, Stransham-Ford presents a learning opportunity for both sides of the legalisation divide. In particular, conceptual errors pertaining to human dignity were made in Stransham-Ford, and can be avoided in future. In this article, I identify these errors and propose the following three corrective principles to inform future debate on the subject: (i) human dignity is violable; (ii) human suffering violates human dignity; and (iii) the 'natural' causes of suffering due to terminal illness do not exclude the application of human dignity.

Bayesian Analysis of Silica Exposure and Lung Cancer Using Human and Animal Studies.

PubMed

Bartell, Scott M; Hamra, Ghassan Badri; Steenland, Kyle

2017-03-01

Bayesian methods can be used to incorporate external information into epidemiologic exposure-response analyses of silica and lung cancer. We used data from a pooled mortality analysis of silica and lung cancer (n = 65,980), using untransformed and log-transformed cumulative exposure. Animal data came from chronic silica inhalation studies using rats. We conducted Bayesian analyses with informative priors based on the animal data and different cross-species extrapolation factors. We also conducted analyses with exposure measurement error corrections in the absence of a gold standard, assuming Berkson-type error that increased with increasing exposure. The pooled animal data exposure-response coefficient was markedly higher (log exposure) or lower (untransformed exposure) than the coefficient for the pooled human data. With 10-fold uncertainty, the animal prior had little effect on results for pooled analyses and only modest effects in some individual studies. One-fold uncertainty produced markedly different results for both pooled and individual studies. Measurement error correction had little effect in pooled analyses using log exposure. Using untransformed exposure, measurement error correction caused a 5% decrease in the exposure-response coefficient for the pooled analysis and marked changes in some individual studies. The animal prior had more impact for smaller human studies and for one-fold versus three- or 10-fold uncertainty. Adjustment for Berkson error using Bayesian methods had little effect on the exposure-response coefficient when exposure was log transformed or when the sample size was large. See video abstract at, http://links.lww.com/EDE/B160.

Safe prescribing: a titanic challenge.

PubMed

Routledge, Philip A

2012-10-01

The challenge to achieve safe prescribing merits the adjective 'titanic'. The organisational and human errors leading to poor prescribing (e.g. underprescribing, overprescribing, misprescribing or medication errors) have parallels in the organisational and human errors that led to the loss of the Titanic 100 years ago this year. Prescribing can be adversely affected by communication failures, critical conditions, complacency, corner cutting, callowness and a lack of courage of conviction, all of which were also factors leading to the Titanic tragedy. These issues need to be addressed by a commitment to excellence, the final component of the 'Seven C's'. Optimal prescribing is dependent upon close communication and collaborative working between highly trained health professionals, whose role is to ensure maximum clinical effectiveness, whilst also protecting their patients from avoidable harm. Since humans are prone to error, and the environments in which they work are imperfect, it is not surprising that medication errors are common, occurring more often during the prescribing stage than during dispensing or administration. A commitment to excellence in prescribing includes a continued focus on lifelong learning (including interprofessional learning) in pharmacology and therapeutics. This should be accompanied by improvements in the clinical working environment of prescribers, and the encouragement of a strong safety culture (including reporting of adverse incidents as well as suspected adverse drug reactions whenever appropriate). Finally, members of the clinical team must be prepared to challenge each other, when necessary, to ensure that prescribing combines the highest likelihood of benefit with the lowest potential for harm. © 2012 The Author. British Journal of Clinical Pharmacology © 2012 The British Pharmacological Society.

Effect of Transducer Orientation on Errors in Ultrasound Image-Based Measurements of Human Medial Gastrocnemius Muscle Fascicle Length and Pennation

PubMed Central

Gandevia, Simon C.; Herbert, Robert D.

2016-01-01

Ultrasound imaging is often used to measure muscle fascicle lengths and pennation angles in human muscles in vivo. Theoretically the most accurate measurements are made when the transducer is oriented so that the image plane aligns with muscle fascicles and, for measurements of pennation, when the image plane also intersects the aponeuroses perpendicularly. However this orientation is difficult to achieve and usually there is some degree of misalignment. Here, we used simulated ultrasound images based on three-dimensional models of the human medial gastrocnemius, derived from magnetic resonance and diffusion tensor images, to describe the relationship between transducer orientation and measurement errors. With the transducer oriented perpendicular to the surface of the leg, the error in measurement of fascicle lengths was about 0.4 mm per degree of misalignment of the ultrasound image with the muscle fascicles. If the transducer is then tipped by 20°, the error increases to 1.1 mm per degree of misalignment. For a given degree of misalignment of muscle fascicles with the image plane, the smallest absolute error in fascicle length measurements occurs when the transducer is held perpendicular to the surface of the leg. Misalignment of the transducer with the fascicles may cause fascicle length measurements to be underestimated or overestimated. Contrary to widely held beliefs, it is shown that pennation angles are always overestimated if the image is not perpendicular to the aponeurosis, even when the image is perfectly aligned with the fascicles. An analytical explanation is provided for this finding. PMID:27294280

Effect of Transducer Orientation on Errors in Ultrasound Image-Based Measurements of Human Medial Gastrocnemius Muscle Fascicle Length and Pennation.

PubMed

Bolsterlee, Bart; Gandevia, Simon C; Herbert, Robert D

2016-01-01

Ultrasound imaging is often used to measure muscle fascicle lengths and pennation angles in human muscles in vivo. Theoretically the most accurate measurements are made when the transducer is oriented so that the image plane aligns with muscle fascicles and, for measurements of pennation, when the image plane also intersects the aponeuroses perpendicularly. However this orientation is difficult to achieve and usually there is some degree of misalignment. Here, we used simulated ultrasound images based on three-dimensional models of the human medial gastrocnemius, derived from magnetic resonance and diffusion tensor images, to describe the relationship between transducer orientation and measurement errors. With the transducer oriented perpendicular to the surface of the leg, the error in measurement of fascicle lengths was about 0.4 mm per degree of misalignment of the ultrasound image with the muscle fascicles. If the transducer is then tipped by 20°, the error increases to 1.1 mm per degree of misalignment. For a given degree of misalignment of muscle fascicles with the image plane, the smallest absolute error in fascicle length measurements occurs when the transducer is held perpendicular to the surface of the leg. Misalignment of the transducer with the fascicles may cause fascicle length measurements to be underestimated or overestimated. Contrary to widely held beliefs, it is shown that pennation angles are always overestimated if the image is not perpendicular to the aponeurosis, even when the image is perfectly aligned with the fascicles. An analytical explanation is provided for this finding.

An Evidential Reasoning-Based CREAM to Human Reliability Analysis in Maritime Accident Process.

PubMed

Wu, Bing; Yan, Xinping; Wang, Yang; Soares, C Guedes

2017-10-01

This article proposes a modified cognitive reliability and error analysis method (CREAM) for estimating the human error probability in the maritime accident process on the basis of an evidential reasoning approach. This modified CREAM is developed to precisely quantify the linguistic variables of the common performance conditions and to overcome the problem of ignoring the uncertainty caused by incomplete information in the existing CREAM models. Moreover, this article views maritime accident development from the sequential perspective, where a scenario- and barrier-based framework is proposed to describe the maritime accident process. This evidential reasoning-based CREAM approach together with the proposed accident development framework are applied to human reliability analysis of a ship capsizing accident. It will facilitate subjective human reliability analysis in different engineering systems where uncertainty exists in practice. © 2017 Society for Risk Analysis.

Human Factors in Financial Trading

PubMed Central

Leaver, Meghan; Reader, Tom W.

2016-01-01

Objective This study tests the reliability of a system (FINANS) to collect and analyze incident reports in the financial trading domain and is guided by a human factors taxonomy used to describe error in the trading domain. Background Research indicates the utility of applying human factors theory to understand error in finance, yet empirical research is lacking. We report on the development of the first system for capturing and analyzing human factors–related issues in operational trading incidents. Method In the first study, 20 incidents are analyzed by an expert user group against a referent standard to establish the reliability of FINANS. In the second study, 750 incidents are analyzed using distribution, mean, pathway, and associative analysis to describe the data. Results Kappa scores indicate that categories within FINANS can be reliably used to identify and extract data on human factors–related problems underlying trading incidents. Approximately 1% of trades (n = 750) lead to an incident. Slip/lapse (61%), situation awareness (51%), and teamwork (40%) were found to be the most common problems underlying incidents. For the most serious incidents, problems in situation awareness and teamwork were most common. Conclusion We show that (a) experts in the trading domain can reliably and accurately code human factors in incidents, (b) 1% of trades incur error, and (c) poor teamwork skills and situation awareness underpin the most critical incidents. Application This research provides data crucial for ameliorating risk within financial trading organizations, with implications for regulation and policy. PMID:27142394

The application of robotics to microlaryngeal laser surgery.

PubMed

Buckmire, Robert A; Wong, Yu-Tung; Deal, Allison M

2015-06-01

To evaluate the performance of human subjects, using a prototype robotic micromanipulator controller in a simulated, microlaryngeal operative setting. Observational cross-sectional study. Twenty-two human subjects with varying degrees of laser experience performed CO2 laser surgical tasks within a simulated microlaryngeal operative setting using an industry standard manual micromanipulator (MMM) and a prototype robotic micromanipulator controller (RMC). Accuracy, repeatability, and ablation consistency measures were obtained for each human subject across both conditions and for the preprogrammed RMC device. Using the standard MMM, surgeons with >10 previous laser cases performed superior to subjects with fewer cases on measures of error percentage and cumulative error (P = .045 and .03, respectively). No significant differences in performance were observed between subjects using the RMC device. In the programmed (P/A) mode, the RMC performed equivalently or superiorly to experienced human subjects on accuracy and repeatability measures, and nearly an order of magnitude better on measures of ablation consistency. The programmed RMC performed significantly better for repetition error when compared to human subjects with <100 previous laser cases (P = .04). Experienced laser surgeons perform better than novice surgeons on tasks of accuracy and repeatability using the MMM device but roughly equivalently using the novel RMC. Operated in the P/A mode, the RMC performs equivalently or superior to experienced laser surgeons using the industry standard MMM for all measured parameters, and delivers an ablation consistency nearly an order of magnitude better than human laser operators. NA. © 2014 The American Laryngological, Rhinological and Otological Society, Inc.

Improving Safety through Human Factors Engineering.

PubMed

Siewert, Bettina; Hochman, Mary G

2015-10-01

Human factors engineering (HFE) focuses on the design and analysis of interactive systems that involve people, technical equipment, and work environment. HFE is informed by knowledge of human characteristics. It complements existing patient safety efforts by specifically taking into consideration that, as humans, frontline staff will inevitably make mistakes. Therefore, the systems with which they interact should be designed for the anticipation and mitigation of human errors. The goal of HFE is to optimize the interaction of humans with their work environment and technical equipment to maximize safety and efficiency. Special safeguards include usability testing, standardization of processes, and use of checklists and forcing functions. However, the effectiveness of the safety program and resiliency of the organization depend on timely reporting of all safety events independent of patient harm, including perceived potential risks, bad outcomes that occur even when proper protocols have been followed, and episodes of "improvisation" when formal guidelines are found not to exist. Therefore, an institution must adopt a robust culture of safety, where the focus is shifted from blaming individuals for errors to preventing future errors, and where barriers to speaking up-including barriers introduced by steep authority gradients-are minimized. This requires creation of formal guidelines to address safety concerns, establishment of unified teams with open communication and shared responsibility for patient safety, and education of managers and senior physicians to perceive the reporting of safety concerns as a benefit rather than a threat. © RSNA, 2015.

Differences among Job Positions Related to Communication Errors at Construction Sites

NASA Astrophysics Data System (ADS)

Takahashi, Akiko; Ishida, Toshiro

In a previous study, we classified the communicatio n errors at construction sites as faulty intention and message pattern, inadequate channel pattern, and faulty comprehension pattern. This study seeks to evaluate the degree of risk of communication errors and to investigate differences among people in various job positions in perception of communication error risk . Questionnaires based on the previous study were a dministered to construction workers (n=811; 149 adminis trators, 208 foremen and 454 workers). Administrators evaluated all patterns of communication error risk equally. However, foremen and workers evaluated communication error risk differently in each pattern. The common contributing factors to all patterns wer e inadequate arrangements before work and inadequate confirmation. Some factors were common among patterns but other factors were particular to a specific pattern. To help prevent future accidents at construction sites, administrators should understand how people in various job positions perceive communication errors and propose human factors measures to prevent such errors.

Application of the epidemiological model in studying human error in aviation

NASA Technical Reports Server (NTRS)

Cheaney, E. S.; Billings, C. E.

1981-01-01

An epidemiological model is described in conjunction with the analytical process through which aviation occurrence reports are composed into the events and factors pertinent to it. The model represents a process in which disease, emanating from environmental conditions, manifests itself in symptoms that may lead to fatal illness, recoverable illness, or no illness depending on individual circumstances of patient vulnerability, preventive actions, and intervention. In the aviation system the analogy of the disease process is the predilection for error of human participants. This arises from factors in the operating or physical environment and results in errors of commission or omission that, again depending on the individual circumstances, may lead to accidents, system perturbations, or harmless corrections. A discussion of the previous investigations, each of which manifests the application of the epidemiological method, exemplifies its use and effectiveness.

Body position reproducibility and joint alignment stability criticality on a muscular strength research device

NASA Astrophysics Data System (ADS)

Nunez, F.; Romero, A.; Clua, J.; Mas, J.; Tomas, A.; Catalan, A.; Castellsaguer, J.

2005-08-01

MARES (Muscle Atrophy Research and Exercise System) is a computerized ergometer for neuromuscular research to be flown and installed onboard the International Space Station in 2007. Validity of data acquired depends on controlling and reducing all significant error sources. One of them is the misalignment of the joint rotation axis with respect to the motor axis.The error induced on the measurements is proportional to the misalignment between both axis. Therefore, the restraint system's performance is critical [1]. MARES HRS (Human Restraint System) assures alignment within an acceptable range while performing the exercise (results: elbow movement:13.94mm+/-5.45, Knee movement: 22.36mm+/- 6.06 ) and reproducibility of human positioning (results: elbow movement: 2.82mm+/-1.56, Knee movement 7.45mm+/-4.8 ). These results allow limiting measurement errors induced by misalignment.

Analysis of the “naming game” with learning errors in communications

NASA Astrophysics Data System (ADS)

Lou, Yang; Chen, Guanrong

2015-07-01

Naming game simulates the process of naming an objective by a population of agents organized in a certain communication network. By pair-wise iterative interactions, the population reaches consensus asymptotically. We study naming game with communication errors during pair-wise conversations, with error rates in a uniform probability distribution. First, a model of naming game with learning errors in communications (NGLE) is proposed. Then, a strategy for agents to prevent learning errors is suggested. To that end, three typical topologies of communication networks, namely random-graph, small-world and scale-free networks, are employed to investigate the effects of various learning errors. Simulation results on these models show that 1) learning errors slightly affect the convergence speed but distinctively increase the requirement for memory of each agent during lexicon propagation; 2) the maximum number of different words held by the population increases linearly as the error rate increases; 3) without applying any strategy to eliminate learning errors, there is a threshold of the learning errors which impairs the convergence. The new findings may help to better understand the role of learning errors in naming game as well as in human language development from a network science perspective.

Analysis of the "naming game" with learning errors in communications.

PubMed

Lou, Yang; Chen, Guanrong

2015-07-16

Naming game simulates the process of naming an objective by a population of agents organized in a certain communication network. By pair-wise iterative interactions, the population reaches consensus asymptotically. We study naming game with communication errors during pair-wise conversations, with error rates in a uniform probability distribution. First, a model of naming game with learning errors in communications (NGLE) is proposed. Then, a strategy for agents to prevent learning errors is suggested. To that end, three typical topologies of communication networks, namely random-graph, small-world and scale-free networks, are employed to investigate the effects of various learning errors. Simulation results on these models show that 1) learning errors slightly affect the convergence speed but distinctively increase the requirement for memory of each agent during lexicon propagation; 2) the maximum number of different words held by the population increases linearly as the error rate increases; 3) without applying any strategy to eliminate learning errors, there is a threshold of the learning errors which impairs the convergence. The new findings may help to better understand the role of learning errors in naming game as well as in human language development from a network science perspective.

Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out?

PubMed

Suba, Eric J; Pfeifer, John D; Raab, Stephen S

2007-10-01

Patient identification errors in surgical pathology often involve switches of prostate or breast needle core biopsy specimens among patients. We assessed strategies for decreasing the occurrence of these uncommon and yet potentially catastrophic events. Root cause analyses were performed following 3 cases of patient identification error involving prostate needle core biopsy specimens. Patient identification errors in surgical pathology result from slips and lapses of automatic human action that may occur at numerous steps during pre-laboratory, laboratory and post-laboratory work flow processes. Patient identification errors among prostate needle biopsies may be difficult to entirely prevent through the optimization of work flow processes. A DNA time-out, whereby DNA polymorphic microsatellite analysis is used to confirm patient identification before radiation therapy or radical surgery, may eliminate patient identification errors among needle biopsies.

Human Systems Integration in Expeditionary Medical Treatment Facilities

DTIC Science & Technology

2010-04-01

mental models and situation awareness Human Factors Engineering, Personnel, and Safety / Occupational Health The following issue is associated with...domains are human factors engineering, manpower, personnel, training, safety and occupational health , survivability, habitability, and environment...certain responsibilities to less-qualified personnel. Human error is a particularly sensitive topic across all sectors of health care, but the time

"Non-Vocalization": A Phonological Error Process in the Speech of Severely and Profoundly Hearing Impaired Adults, from the Point of View of the Theory of Phonology as Human Behaviour

ERIC Educational Resources Information Center

Halpern, Orly; Tobin, Yishai

2008-01-01

"Non-vocalization" (N-V) is a newly described phonological error process in hearing impaired speakers. In N-V the hearing impaired person actually articulates the phoneme but without producing a voice. The result is an error process looking as if it is produced but sounding as if it is omitted. N-V was discovered by video recording the speech of…

Overview of medical errors and adverse events

PubMed Central

2012-01-01

Safety is a global concept that encompasses efficiency, security of care, reactivity of caregivers, and satisfaction of patients and relatives. Patient safety has emerged as a major target for healthcare improvement. Quality assurance is a complex task, and patients in the intensive care unit (ICU) are more likely than other hospitalized patients to experience medical errors, due to the complexity of their conditions, need for urgent interventions, and considerable workload fluctuation. Medication errors are the most common medical errors and can induce adverse events. Two approaches are available for evaluating and improving quality-of-care: the room-for-improvement model, in which problems are identified, plans are made to resolve them, and the results of the plans are measured; and the monitoring model, in which quality indicators are defined as relevant to potential problems and then monitored periodically. Indicators that reflect structures, processes, or outcomes have been developed by medical societies. Surveillance of these indicators is organized at the hospital or national level. Using a combination of methods improves the results. Errors are caused by combinations of human factors and system factors, and information must be obtained on how people make errors in the ICU environment. Preventive strategies are more likely to be effective if they rely on a system-based approach, in which organizational flaws are remedied, rather than a human-based approach of encouraging people not to make errors. The development of a safety culture in the ICU is crucial to effective prevention and should occur before the evaluation of safety programs, which are more likely to be effective when they involve bundles of measures. PMID:22339769

Human Reliability and Ship Stability

DTIC Science & Technology

2003-07-04

models such as Miller (1957) and Broadbent (1959) is the idea of human beings as limited capacity information processors with constraints on...15 4.2.2 Outline of Some Key models ...23 TABLE 11: GENERIC ERROR MODELING SYSTEM

Translating Research Into Practice: Voluntary Reporting of Medication Errors in Critical Access Hospitals

ERIC Educational Resources Information Center

Jones, Katherine J.; Cochran, Gary; Hicks, Rodney W.; Mueller, Keith J.

2004-01-01

Context:Low service volume, insufficient information technology, and limited human resources are barriers to learning about and correcting system failures in small rural hospitals. This paper describes the implementation of and initial findings from a voluntary medication error reporting program developed by the Nebraska Center for Rural Health…

Considerations for Creating Multi-Language Personality Norms: A Three-Component Model of Error

ERIC Educational Resources Information Center

Meyer, Kevin D.; Foster, Jeff L.

2008-01-01

With the increasing globalization of human resources practices, a commensurate increase in demand has occurred for multi-language ("global") personality norms for use in selection and development efforts. The combination of data from multiple translations of a personality assessment into a single norm engenders error from multiple sources. This…

45 CFR 61.6 - Reporting errors, omissions, revisions or whether an action is on appeal.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 45 Public Welfare 1 2011-10-01 2011-10-01 false Reporting errors, omissions, revisions or whether an action is on appeal. 61.6 Section 61.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION HEALTHCARE INTEGRITY AND PROTECTION DATA BANK FOR FINAL ADVERSE INFORMATION ON...

45 CFR 61.6 - Reporting errors, omissions, revisions or whether an action is on appeal.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 45 Public Welfare 1 2012-10-01 2012-10-01 false Reporting errors, omissions, revisions or whether an action is on appeal. 61.6 Section 61.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION HEALTHCARE INTEGRITY AND PROTECTION DATA BANK FOR FINAL ADVERSE INFORMATION ON...

45 CFR 61.6 - Reporting errors, omissions, revisions or whether an action is on appeal.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 45 Public Welfare 1 2010-10-01 2010-10-01 false Reporting errors, omissions, revisions or whether an action is on appeal. 61.6 Section 61.6 Public Welfare DEPARTMENT OF HEALTH AND HUMAN SERVICES GENERAL ADMINISTRATION HEALTHCARE INTEGRITY AND PROTECTION DATA BANK FOR FINAL ADVERSE INFORMATION ON...

Understanding Teamwork in Trauma Resuscitation through Analysis of Team Errors

ERIC Educational Resources Information Center

Sarcevic, Aleksandra

2009-01-01

An analysis of human errors in complex work settings can lead to important insights into the workspace design. This type of analysis is particularly relevant to safety-critical, socio-technical systems that are highly dynamic, stressful and time-constrained, and where failures can result in catastrophic societal, economic or environmental…

STATISTICAL DISTRIBUTIONS OF PARTICULATE MATTER AND THE ERROR ASSOCIATED WITH SAMPLING FREQUENCY. (R828678C010)

EPA Science Inventory

The distribution of particulate matter (PM) concentrations has an impact on human health effects and the setting of PM regulations. Since PM is commonly sampled on less than daily schedules, the magnitude of sampling errors needs to be determined. Daily PM data from Spokane, W...

Less Pain, More Gain: Rapid Skill Development Using "Old Way New Way"

ERIC Educational Resources Information Center

Baxter, Paul; Lyndon, Harry; Dole, Shelley; Battistutta, Diana

2004-01-01

This study addresses an issue of global concern in skills training, namely, the rapid and permanent eradication of persistent habit errors, and bad or unsafe working practices. This article offers an alternative human factors explanation for the profound difficulties and low transfer of training experienced during error pattern retraining, and the…

A Generalized Process Model of Human Action Selection and Error and its Application to Error Prediction

DTIC Science & Technology

2014-07-01

Macmillan & Creelman , 2005). This is a quite high degree of discriminability and it means that when the decision model predicts a probability of...ROC analysis. Pattern Recognition Letters, 27(8), 861-874. Retrieved from Google Scholar. Macmillan, N. A., & Creelman , C. D. (2005). Detection

49 CFR Appendix C to Part 236 - Safety Assurance Criteria and Processes

Code of Federal Regulations, 2010 CFR

2010-10-01

... system (all its elements including hardware and software) must be designed to assure safe operation with... unsafe errors in the software due to human error in the software specification, design, or coding phases... (hardware or software, or both) are used in combination to ensure safety. If a common mode failure exists...

Pilot interaction with automated airborne decision making systems

NASA Technical Reports Server (NTRS)

Hammer, John M.; Wan, C. Yoon; Vasandani, Vijay

1987-01-01

The current research is focused on detection of human error and protection from its consequences. A program for monitoring pilot error by comparing pilot actions to a script was described. It dealt primarily with routine errors (slips) that occurred during checklist activity. The model to which operator actions were compared was a script. Current research is an extension along these two dimensions. The ORS fault detection aid uses a sophisticated device model rather than a script. The newer initiative, the model-based and constraint-based warning system, uses an even more sophisticated device model and is to prevent all types of error, not just slips or bad decision.

Increased User Satisfaction Through an Improved Message System

NASA Technical Reports Server (NTRS)

Weissert, C. L.

1997-01-01

With all of the enhancements in software methodology and testing, there is no guarantee that software can be delivered such that no user errors occur, How to handle these errors when they occur has become a major research topic within human-computer interaction (HCI). Users of the Multimission Spacecraft Analysis Subsystem(MSAS) at the Jet Propulsion Laboratory (JPL), a system of X and motif graphical user interfaces for analyzing spacecraft data, complained about the lack of information about the error cause and have suggested that recovery actions be included in the system error messages...The system was evaluated through usability surveys and was shown to be successful.

Dialysis Facility Safety: Processes and Opportunities.

PubMed

Garrick, Renee; Morey, Rishikesh

2015-01-01

Unintentional human errors are the source of most safety breaches in complex, high-risk environments. The environment of dialysis care is extremely complex. Dialysis patients have unique and changing physiology, and the processes required for their routine care involve numerous open-ended interfaces between providers and an assortment of technologically advanced equipment. Communication errors, both within the dialysis facility and during care transitions, and lapses in compliance with policies and procedures are frequent areas of safety risk. Some events, such as air emboli and needle dislodgments occur infrequently, but are serious risks. Other adverse events include medication errors, patient falls, catheter and access-related infections, access infiltrations and prolonged bleeding. A robust safety system should evaluate how multiple, sequential errors might align to cause harm. Systems of care can be improved by sharing the results of root cause analyses, and "good catches." Failure mode effects and analyses can be used to proactively identify and mitigate areas of highest risk, and methods drawn from cognitive psychology, simulation training, and human factor engineering can be used to advance facility safety. © 2015 Wiley Periodicals, Inc.

Neural dynamics of reward probability coding: a Magnetoencephalographic study in humans

PubMed Central

Thomas, Julie; Vanni-Mercier, Giovanna; Dreher, Jean-Claude

2013-01-01

Prediction of future rewards and discrepancy between actual and expected outcomes (prediction error) are crucial signals for adaptive behavior. In humans, a number of fMRI studies demonstrated that reward probability modulates these two signals in a large brain network. Yet, the spatio-temporal dynamics underlying the neural coding of reward probability remains unknown. Here, using magnetoencephalography, we investigated the neural dynamics of prediction and reward prediction error computations while subjects learned to associate cues of slot machines with monetary rewards with different probabilities. We showed that event-related magnetic fields (ERFs) arising from the visual cortex coded the expected reward value 155 ms after the cue, demonstrating that reward value signals emerge early in the visual stream. Moreover, a prediction error was reflected in ERF peaking 300 ms after the rewarded outcome and showing decreasing amplitude with higher reward probability. This prediction error signal was generated in a network including the anterior and posterior cingulate cortex. These findings pinpoint the spatio-temporal characteristics underlying reward probability coding. Together, our results provide insights into the neural dynamics underlying the ability to learn probabilistic stimuli-reward contingencies. PMID:24302894

An Interview with a Dolphin.

ERIC Educational Resources Information Center

Brook, Kathy; Keilty, Jennifer

1993-01-01

A fabricated conversation between two humans and a dolphin at Marineland illustrates man's relationship to nature and the impact that human actions have on living creatures and the environment, and stresses developing a deeper understanding and value for the natural world and consideration of the universality of continued human error and…

Errare machinale est: the use of error-related potentials in brain-machine interfaces

PubMed Central

Chavarriaga, Ricardo; Sobolewski, Aleksander; Millán, José del R.

2014-01-01

The ability to recognize errors is crucial for efficient behavior. Numerous studies have identified electrophysiological correlates of error recognition in the human brain (error-related potentials, ErrPs). Consequently, it has been proposed to use these signals to improve human-computer interaction (HCI) or brain-machine interfacing (BMI). Here, we present a review of over a decade of developments toward this goal. This body of work provides consistent evidence that ErrPs can be successfully detected on a single-trial basis, and that they can be effectively used in both HCI and BMI applications. We first describe the ErrP phenomenon and follow up with an analysis of different strategies to increase the robustness of a system by incorporating single-trial ErrP recognition, either by correcting the machine's actions or by providing means for its error-based adaptation. These approaches can be applied both when the user employs traditional HCI input devices or in combination with another BMI channel. Finally, we discuss the current challenges that have to be overcome in order to fully integrate ErrPs into practical applications. This includes, in particular, the characterization of such signals during real(istic) applications, as well as the possibility of extracting richer information from them, going beyond the time-locked decoding that dominates current approaches. PMID:25100937

How Angular Velocity Features and Different Gyroscope Noise Types Interact and Determine Orientation Estimation Accuracy.

PubMed

Pasciuto, Ilaria; Ligorio, Gabriele; Bergamini, Elena; Vannozzi, Giuseppe; Sabatini, Angelo Maria; Cappozzo, Aurelio

2015-09-18

In human movement analysis, 3D body segment orientation can be obtained through the numerical integration of gyroscope signals. These signals, however, are affected by errors that, for the case of micro-electro-mechanical systems, are mainly due to: constant bias, scale factor, white noise, and bias instability. The aim of this study is to assess how the orientation estimation accuracy is affected by each of these disturbances, and whether it is influenced by the angular velocity magnitude and 3D distribution across the gyroscope axes. Reference angular velocity signals, either constant or representative of human walking, were corrupted with each of the four noise types within a simulation framework. The magnitude of the angular velocity affected the error in the orientation estimation due to each noise type, except for the white noise. Additionally, the error caused by the constant bias was also influenced by the angular velocity 3D distribution. As the orientation error depends not only on the noise itself but also on the signal it is applied to, different sensor placements could enhance or mitigate the error due to each disturbance, and special attention must be paid in providing and interpreting measures of accuracy for orientation estimation algorithms.

How Angular Velocity Features and Different Gyroscope Noise Types Interact and Determine Orientation Estimation Accuracy

PubMed Central

Pasciuto, Ilaria; Ligorio, Gabriele; Bergamini, Elena; Vannozzi, Giuseppe; Sabatini, Angelo Maria; Cappozzo, Aurelio

2015-01-01

In human movement analysis, 3D body segment orientation can be obtained through the numerical integration of gyroscope signals. These signals, however, are affected by errors that, for the case of micro-electro-mechanical systems, are mainly due to: constant bias, scale factor, white noise, and bias instability. The aim of this study is to assess how the orientation estimation accuracy is affected by each of these disturbances, and whether it is influenced by the angular velocity magnitude and 3D distribution across the gyroscope axes. Reference angular velocity signals, either constant or representative of human walking, were corrupted with each of the four noise types within a simulation framework. The magnitude of the angular velocity affected the error in the orientation estimation due to each noise type, except for the white noise. Additionally, the error caused by the constant bias was also influenced by the angular velocity 3D distribution. As the orientation error depends not only on the noise itself but also on the signal it is applied to, different sensor placements could enhance or mitigate the error due to each disturbance, and special attention must be paid in providing and interpreting measures of accuracy for orientation estimation algorithms. PMID:26393606

Routes to failure: analysis of 41 civil aviation accidents from the Republic of China using the human factors analysis and classification system.

PubMed

Li, Wen-Chin; Harris, Don; Yu, Chung-San

2008-03-01

The human factors analysis and classification system (HFACS) is based upon Reason's organizational model of human error. HFACS was developed as an analytical framework for the investigation of the role of human error in aviation accidents, however, there is little empirical work formally describing the relationship between the components in the model. This research analyses 41 civil aviation accidents occurring to aircraft registered in the Republic of China (ROC) between 1999 and 2006 using the HFACS framework. The results show statistically significant relationships between errors at the operational level and organizational inadequacies at both the immediately adjacent level (preconditions for unsafe acts) and higher levels in the organization (unsafe supervision and organizational influences). The pattern of the 'routes to failure' observed in the data from this analysis of civil aircraft accidents show great similarities to that observed in the analysis of military accidents. This research lends further support to Reason's model that suggests that active failures are promoted by latent conditions in the organization. Statistical relationships linking fallible decisions in upper management levels were found to directly affect supervisory practices, thereby creating the psychological preconditions for unsafe acts and hence indirectly impairing the performance of pilots, ultimately leading to accidents.

Improved Quick Disconnect (QD) Interface Through Fail Safe Parts Identification

NASA Technical Reports Server (NTRS)

Blanch-Payne, Evelyn

2001-01-01

An extensive review of existing Quick Disconnects (QDs) mating and demating operations was performed to determine which shuttle part interface identifications and procedures contribute to human factor errors. The research methods used consisted of interviews with engineers and technicians, examination of incident reports, critiques of video and audio tapes of QD operations, and attendance of a Hyper QD operational course. The data strongly suggests that there are inherit human factor errors involved in QD operations. To promote fail-safe operations, QD interface problem areas and recommendations were outlined and reviewed. It is suggested that dialogue, investigations and recommendations continue.

The effects of multiple aerospace environmental stressors on human performance

NASA Technical Reports Server (NTRS)

Popper, S. E.; Repperger, D. W.; Mccloskey, K.; Tripp, L. D.

1992-01-01

An extended Fitt's law paradigm reaction time (RT) task was used to evaluate the effects of acceleration on human performance in the Dynamic Environment Simulator (DES) at Armstrong Laboratory, Wright-Patterson AFB, Ohio. This effort was combined with an evaluation of the standard CSU-13 P anti-gravity suit versus three configurations of a 'retrograde inflation anti-G suit'. Results indicated that RT and error rates increased 17 percent and 14 percent respectively from baseline to the end of the simulated aerial combat maneuver and that the most common error was pressing too few buttons.

Multivariable manual control with simultaneous visual and auditory presentation of information. [for improved compensatory tracking performance of human operator

NASA Technical Reports Server (NTRS)

Uhlemann, H.; Geiser, G.

1975-01-01

Multivariable manual compensatory tracking experiments were carried out in order to determine typical strategies of the human operator and conditions for improvement of his performance if one of the visual displays of the tracking errors is supplemented by an auditory feedback. Because the tracking error of the system which is only visually displayed is found to decrease, but not in general that of the auditorally supported system, it was concluded that the auditory feedback unloads the visual system of the operator who can then concentrate on the remaining exclusively visual displays.

On Space Exploration and Human Error: A Paper on Reliability and Safety

NASA Technical Reports Server (NTRS)

Bell, David G.; Maluf, David A.; Gawdiak, Yuri

2005-01-01

NASA space exploration should largely address a problem class in reliability and risk management stemming primarily from human error, system risk and multi-objective trade-off analysis, by conducting research into system complexity, risk characterization and modeling, and system reasoning. In general, in every mission we can distinguish risk in three possible ways: a) known-known, b) known-unknown, and c) unknown-unknown. It is probably almost certain that space exploration will partially experience similar known or unknown risks embedded in the Apollo missions, Shuttle or Station unless something alters how NASA will perceive and manage safety and reliability

Evidence of Selection against Complex Mitotic-Origin Aneuploidy during Preimplantation Development

PubMed Central

McCoy, Rajiv C.; Demko, Zachary P.; Ryan, Allison; Banjevic, Milena; Hill, Matthew; Sigurjonsson, Styrmir; Rabinowitz, Matthew; Petrov, Dmitri A.

2015-01-01

Whole-chromosome imbalances affect over half of early human embryos and are the leading cause of pregnancy loss. While these errors frequently arise in oocyte meiosis, many such whole-chromosome abnormalities affecting cleavage-stage embryos are the result of chromosome missegregation occurring during the initial mitotic cell divisions. The first wave of zygotic genome activation at the 4–8 cell stage results in the arrest of a large proportion of embryos, the vast majority of which contain whole-chromosome abnormalities. Thus, the full spectrum of meiotic and mitotic errors can only be detected by sampling after the initial cell divisions, but prior to this selective filter. Here, we apply 24-chromosome preimplantation genetic screening (PGS) to 28,052 single-cell day-3 blastomere biopsies and 18,387 multi-cell day-5 trophectoderm biopsies from 6,366 in vitro fertilization (IVF) cycles. We precisely characterize the rates and patterns of whole-chromosome abnormalities at each developmental stage and distinguish errors of meiotic and mitotic origin without embryo disaggregation, based on informative chromosomal signatures. We show that mitotic errors frequently involve multiple chromosome losses that are not biased toward maternal or paternal homologs. This outcome is characteristic of spindle abnormalities and chaotic cell division detected in previous studies. In contrast to meiotic errors, our data also show that mitotic errors are not significantly associated with maternal age. PGS patients referred due to previous IVF failure had elevated rates of mitotic error, while patients referred due to recurrent pregnancy loss had elevated rates of meiotic error, controlling for maternal age. These results support the conclusion that mitotic error is the predominant mechanism contributing to pregnancy losses occurring prior to blastocyst formation. This high-resolution view of the full spectrum of whole-chromosome abnormalities affecting early embryos provides insight into the cytogenetic mechanisms underlying their formation and the consequences for human fertility. PMID:26491874

Transcriptional fidelities of human mitochondrial POLRMT, yeast mitochondrial Rpo41, and phage T7 single-subunit RNA polymerases.

PubMed

Sultana, Shemaila; Solotchi, Mihai; Ramachandran, Aparna; Patel, Smita S

2017-11-03

Single-subunit RNA polymerases (RNAPs) are present in phage T7 and in mitochondria of all eukaryotes. This RNAP class plays important roles in biotechnology and cellular energy production, but we know little about its fidelity and error rates. Herein, we report the error rates of three single-subunit RNAPs measured from the catalytic efficiencies of correct and all possible incorrect nucleotides. The average error rates of T7 RNAP (2 × 10 -6 ), yeast mitochondrial Rpo41 (6 × 10 -6 ), and human mitochondrial POLRMT (RNA polymerase mitochondrial) (2 × 10 -5 ) indicate high accuracy/fidelity of RNA synthesis resembling those of replicative DNA polymerases. All three RNAPs exhibit a distinctly high propensity for GTP misincorporation opposite dT, predicting frequent A→G errors in RNA with rates of ∼10 -4 The A→C, G→A, A→U, C→U, G→U, U→C, and U→G errors mostly due to pyrimidine-purine mismatches were relatively frequent (10 -5 -10 -6 ), whereas C→G, U→A, G→C, and C→A errors from purine-purine and pyrimidine-pyrimidine mismatches were rare (10 -7 -10 -10 ). POLRMT also shows a high C→A error rate on 8-oxo-dG templates (∼10 -4 ). Strikingly, POLRMT shows a high mutagenic bypass rate, which is exacerbated by TEFM (transcription elongation factor mitochondrial). The lifetime of POLRMT on terminally mismatched elongation substrate is increased in the presence of TEFM, which allows POLRMT to efficiently bypass the error and continue with transcription. This investigation of nucleotide selectivity on normal and oxidatively damaged DNA by three single-subunit RNAPs provides the basic information to understand the error rates in mitochondria and, in the case of T7 RNAP, to assess the quality of in vitro transcribed RNAs. © 2017 by The American Society for Biochemistry and Molecular Biology, Inc.

Understanding adverse events: human factors.

PubMed Central

Reason, J

1995-01-01

(1) Human rather than technical failures now represent the greatest threat to complex and potentially hazardous systems. This includes healthcare systems. (2) Managing the human risks will never be 100% effective. Human fallibility can be moderated, but it cannot be eliminated. (3) Different error types have different underlying mechanisms, occur in different parts of the organisation, and require different methods of risk management. The basic distinctions are between: Slips, lapses, trips, and fumbles (execution failures) and mistakes (planning or problem solving failures). Mistakes are divided into rule based mistakes and knowledge based mistakes. Errors (information-handling problems) and violations (motivational problems) Active versus latent failures. Active failures are committed by those in direct contact with the patient, latent failures arise in organisational and managerial spheres and their adverse effects may take a long time to become evident. (4) Safety significant errors occur at all levels of the system, not just at the sharp end. Decisions made in the upper echelons of the organisation create the conditions in the workplace that subsequently promote individual errors and violations. Latent failures are present long before an accident and are hence prime candidates for principled risk management. (5) Measures that involve sanctions and exhortations (that is, moralistic measures directed to those at the sharp end) have only very limited effectiveness, especially so in the case of highly trained professionals. (6) Human factors problems are a product of a chain of causes in which the individual psychological factors (that is, momentary inattention, forgetting, etc) are the last and least manageable links. Attentional "capture" (preoccupation or distraction) is a necessary condition for the commission of slips and lapses. Yet, its occurrence is almost impossible to predict or control effectively. The same is true of the factors associated with forgetting. States of mind contributing to error are thus extremely difficult to manage; they can happen to the best of people at any time. (7) People do not act in isolation. Their behaviour is shaped by circumstances. The same is true for errors and violations. The likelihood of an unsafe act being committed is heavily influenced by the nature of the task and by the local workplace conditions. These, in turn, are the product of "upstream" organisational factors. Great gains in safety can ve achieved through relatively small modifications of equipment and workplaces. (8) Automation and increasing advanced equipment do not cure human factors problems, they merely relocate them. In contrast, training people to work effectively in teams costs little, but has achieved significant enhancements of human performance in aviation. (9) Effective risk management depends critically on a confidential and preferable anonymous incident monitoring system that records the individual, task, situational, and organisational factors associated with incidents and near misses. (10) Effective risk management means the simultaneous and targeted deployment of limited remedial resources at different levels of the system: the individual or team, the task, the situation, and the organisation as a whole. PMID:10151618

Skills, rules and knowledge in aircraft maintenance: errors in context

NASA Technical Reports Server (NTRS)

Hobbs, Alan; Williamson, Ann

2002-01-01

Automatic or skill-based behaviour is generally considered to be less prone to error than behaviour directed by conscious control. However, researchers who have applied Rasmussen's skill-rule-knowledge human error framework to accidents and incidents have sometimes found that skill-based errors appear in significant numbers. It is proposed that this is largely a reflection of the opportunities for error which workplaces present and does not indicate that skill-based behaviour is intrinsically unreliable. In the current study, 99 errors reported by 72 aircraft mechanics were examined in the light of a task analysis based on observations of the work of 25 aircraft mechanics. The task analysis identified the opportunities for error presented at various stages of maintenance work packages and by the job as a whole. Once the frequency of each error type was normalized in terms of the opportunities for error, it became apparent that skill-based performance is more reliable than rule-based performance, which is in turn more reliable than knowledge-based performance. The results reinforce the belief that industrial safety interventions designed to reduce errors would best be directed at those aspects of jobs that involve rule- and knowledge-based performance.

Embodying Others in Immersive Virtual Reality: Electro-Cortical Signatures of Monitoring the Errors in the Actions of an Avatar Seen from a First-Person Perspective.

PubMed

Pavone, Enea Francesco; Tieri, Gaetano; Rizza, Giulia; Tidoni, Emmanuele; Grisoni, Luigi; Aglioti, Salvatore Maria

2016-01-13

Brain monitoring of errors in one's own and other's actions is crucial for a variety of processes, ranging from the fine-tuning of motor skill learning to important social functions, such as reading out and anticipating the intentions of others. Here, we combined immersive virtual reality and EEG recording to explore whether embodying the errors of an avatar by seeing it from a first-person perspective may activate the error monitoring system in the brain of an onlooker. We asked healthy participants to observe, from a first- or third-person perspective, an avatar performing a correct or an incorrect reach-to-grasp movement toward one of two virtual mugs placed on a table. At the end of each trial, participants reported verbally how much they embodied the avatar's arm. Ratings were maximal in first-person perspective, indicating that immersive virtual reality can be a powerful tool to induce embodiment of an artificial agent, even through mere visual perception and in the absence of any cross-modal boosting. Observation of erroneous grasping from a first-person perspective enhanced error-related negativity and medial-frontal theta power in the trials where human onlookers embodied the virtual character, hinting at the tight link between early, automatic coding of error detection and sense of embodiment. Error positivity was similar in 1PP and 3PP, suggesting that conscious coding of errors is similar for self and other. Thus, embodiment plays an important role in activating specific components of the action monitoring system when others' errors are coded as if they are one's own errors. Detecting errors in other's actions is crucial for social functions, such as reading out and anticipating the intentions of others. Using immersive virtual reality and EEG recording, we explored how the brain of an onlooker reacted to the errors of an avatar seen from a first-person perspective. We found that mere observation of erroneous actions enhances electrocortical markers of error detection in the trials where human onlookers embodied the virtual character. Thus, the cerebral system for action monitoring is maximally activated when others' errors are coded as if they are one's own errors. The results have important implications for understanding how the brain can control the external world and thus creating new brain-computer interfaces. Copyright © 2016 the authors 0270-6474/16/360268-12$15.00/0.

21 CFR 1040.11 - Specific purpose laser products.

Code of Federal Regulations, 2012 CFR

2012-04-01

... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of...

21 CFR 1040.11 - Specific purpose laser products.

Code of Federal Regulations, 2014 CFR

2014-04-01

... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of...

21 CFR 1040.11 - Specific purpose laser products.

Code of Federal Regulations, 2013 CFR

2013-04-01

... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of...

Hedging Your Bets by Learning Reward Correlations in the Human Brain

PubMed Central

Wunderlich, Klaus; Symmonds, Mkael; Bossaerts, Peter; Dolan, Raymond J.

2011-01-01

Summary Human subjects are proficient at tracking the mean and variance of rewards and updating these via prediction errors. Here, we addressed whether humans can also learn about higher-order relationships between distinct environmental outcomes, a defining ecological feature of contexts where multiple sources of rewards are available. By manipulating the degree to which distinct outcomes are correlated, we show that subjects implemented an explicit model-based strategy to learn the associated outcome correlations and were adept in using that information to dynamically adjust their choices in a task that required a minimization of outcome variance. Importantly, the experimentally generated outcome correlations were explicitly represented neuronally in right midinsula with a learning prediction error signal expressed in rostral anterior cingulate cortex. Thus, our data show that the human brain represents higher-order correlation structures between rewards, a core adaptive ability whose immediate benefit is optimized sampling. PMID:21943609

CBP for Field Workers – Results and Insights from Three Usability and Interface Design Evaluations

DOE Office of Scientific and Technical Information (OSTI.GOV)

Oxstrand, Johanna Helene; Le Blanc, Katya Lee; Bly, Aaron Douglas

2015-09-01

Nearly all activities that involve human interaction with the systems in a nuclear power plant are guided by procedures. Even though the paper-based procedures (PBPs) currently used by industry have a demonstrated history of ensuring safety, improving procedure use could yield significant savings in increased efficiency as well as improved nuclear safety through human performance gains. The nuclear industry is constantly trying to find ways to decrease the human error rate, especially the human errors associated with procedure use. As a step toward the goal of improving procedure use and adherence, researchers in the Light-Water Reactor Sustainability (LWRS) Program, togethermore » with the nuclear industry, have been investigating the possibility and feasibility of replacing the current paper-based procedure process with a computer-based procedure (CBP) system. This report describes a field evaluation of new design concepts of a prototype computer-based procedure system.« less

The impact of human-technology cooperation and distributed cognition in forensic science: biasing effects of AFIS contextual information on human experts.

PubMed

Dror, Itiel E; Wertheim, Kasey; Fraser-Mackenzie, Peter; Walajtys, Jeff

2012-03-01

Experts play a critical role in forensic decision making, even when cognition is offloaded and distributed between human and machine. In this paper, we investigated the impact of using Automated Fingerprint Identification Systems (AFIS) on human decision makers. We provided 3680 AFIS lists (a total of 55,200 comparisons) to 23 latent fingerprint examiners as part of their normal casework. We manipulated the position of the matching print in the AFIS list. The data showed that latent fingerprint examiners were affected by the position of the matching print in terms of false exclusions and false inconclusives. Furthermore, the data showed that false identification errors were more likely at the top of the list and that such errors occurred even when the correct match was present further down the list. These effects need to be studied and considered carefully, so as to optimize human decision making when using technologies such as AFIS. © 2011 American Academy of Forensic Sciences.

Package Design Affects Accuracy Recognition for Medications.

PubMed

Endestad, Tor; Wortinger, Laura A; Madsen, Steinar; Hortemo, Sigurd

2016-12-01

Our aim was to test if highlighting and placement of substance name on medication package have the potential to reduce patient errors. An unintentional overdose of medication is a large health issue that might be linked to medication package design. In two experiments, placement, background color, and the active ingredient of generic medication packages were manipulated according to best human factors guidelines to reduce causes of labeling-related patient errors. In two experiments, we compared the original packaging with packages where we varied placement of the name, dose, and background of the active ingredient. Age-relevant differences and the effect of color on medication recognition error were tested. In Experiment 1, 59 volunteers (30 elderly and 29 young students), participated. In Experiment 2, 25 volunteers participated. The most common error was the inability to identify that two different packages contained the same active ingredient (young, 41%, and elderly, 68%). This kind of error decreased with the redesigned packages (young, 8%, and elderly, 16%). Confusion errors related to color design were reduced by two thirds in the redesigned packages compared with original generic medications. Prominent placement of substance name and dose with a band of high-contrast color support recognition of the active substance in medications. A simple modification including highlighting and placing the name of the active ingredient in the upper right-hand corner of the package helps users realize that two different packages can contain the same active substance, thus reducing the risk of inadvertent medication overdose. © 2016, Human Factors and Ergonomics Society.

"First, know thyself": cognition and error in medicine.

PubMed

Elia, Fabrizio; Aprà, Franco; Verhovez, Andrea; Crupi, Vincenzo

2016-04-01

Although error is an integral part of the world of medicine, physicians have always been little inclined to take into account their own mistakes and the extraordinary technological progress observed in the last decades does not seem to have resulted in a significant reduction in the percentage of diagnostic errors. The failure in the reduction in diagnostic errors, notwithstanding the considerable investment in human and economic resources, has paved the way to new strategies which were made available by the development of cognitive psychology, the branch of psychology that aims at understanding the mechanisms of human reasoning. This new approach led us to realize that we are not fully rational agents able to take decisions on the basis of logical and probabilistically appropriate evaluations. In us, two different and mostly independent modes of reasoning coexist: a fast or non-analytical reasoning, which tends to be largely automatic and fast-reactive, and a slow or analytical reasoning, which permits to give rationally founded answers. One of the features of the fast mode of reasoning is the employment of standardized rules, termed "heuristics." Heuristics lead physicians to correct choices in a large percentage of cases. Unfortunately, cases exist wherein the heuristic triggered fails to fit the target problem, so that the fast mode of reasoning can lead us to unreflectively perform actions exposing us and others to variable degrees of risk. Cognitive errors arise as a result of these cases. Our review illustrates how cognitive errors can cause diagnostic problems in clinical practice.

The Influence of Effortful Thought and Cognitive Proficiencies on the Conjunction Fallacy: Implications for Dual-Process Theories of Reasoning and Judgment.

PubMed

Scherer, Laura D; Yates, J Frank; Baker, S Glenn; Valentine, Kathrene D

2017-06-01

Human judgment often violates normative standards, and virtually no judgment error has received as much attention as the conjunction fallacy. Judgment errors have historically served as evidence for dual-process theories of reasoning, insofar as these errors are assumed to arise from reliance on a fast and intuitive mental process, and are corrected via effortful deliberative reasoning. In the present research, three experiments tested the notion that conjunction errors are reduced by effortful thought. Predictions based on three different dual-process theory perspectives were tested: lax monitoring, override failure, and the Tripartite Model. Results indicated that participants higher in numeracy were less likely to make conjunction errors, but this association only emerged when participants engaged in two-sided reasoning, as opposed to one-sided or no reasoning. Confidence was higher for incorrect as opposed to correct judgments, suggesting that participants were unaware of their errors.

Predictability of the Arctic sea ice edge

NASA Astrophysics Data System (ADS)

Goessling, H. F.; Tietsche, S.; Day, J. J.; Hawkins, E.; Jung, T.

2016-02-01

Skillful sea ice forecasts from days to years ahead are becoming increasingly important for the operation and planning of human activities in the Arctic. Here we analyze the potential predictability of the Arctic sea ice edge in six climate models. We introduce the integrated ice-edge error (IIEE), a user-relevant verification metric defined as the area where the forecast and the "truth" disagree on the ice concentration being above or below 15%. The IIEE lends itself to decomposition into an absolute extent error, corresponding to the common sea ice extent error, and a misplacement error. We find that the often-neglected misplacement error makes up more than half of the climatological IIEE. In idealized forecast ensembles initialized on 1 July, the IIEE grows faster than the absolute extent error. This means that the Arctic sea ice edge is less predictable than sea ice extent, particularly in September, with implications for the potential skill of end-user relevant forecasts.

An investigation of reports of Controlled Flight Toward Terrain (CFTT)

NASA Technical Reports Server (NTRS)

Porter, R. F.; Loomis, J. P.

1981-01-01

Some 258 reports from more than 23,000 documents in the files of the Aviation Safety Reporting System (ASRS) were found to be to the hazard of flight into terrain with no prior awareness by the crew of impending disaster. Examination of the reports indicate that human error was a casual factor in 64% of the incidents in which some threat of terrain conflict was experienced. Approximately two-thirds of the human errors were attributed to controllers, the most common discrepancy being a radar vector below the Minimum Vector Altitude (MVA). Errors by pilots were of a much diverse nature and include a few instances of gross deviations from their assigned altitudes. The ground proximity warning system and the minimum safe altitude warning equipment were the initial recovery factor in some 18 serious incidents and were apparently the sole warning in six reported instances which otherwise would most probably have ended in disaster.

Model-based influences on humans’ choices and striatal prediction errors

PubMed Central

Daw, Nathaniel D.; Gershman, Samuel J.; Seymour, Ben; Dayan, Peter; Dolan, Raymond J.

2011-01-01

Summary The mesostriatal dopamine system is prominently implicated in model-free reinforcement learning, with fMRI BOLD signals in ventral striatum notably covarying with model-free prediction errors. However, latent learning and devaluation studies show that behavior also shows hallmarks of model-based planning, and the interaction between model-based and model-free values, prediction errors and preferences is underexplored. We designed a multistep decision task in which model-based and model-free influences on human choice behavior could be distinguished. By showing that choices reflected both influences we could then test the purity of the ventral striatal BOLD signal as a model-free report. Contrary to expectations, the signal reflected both model-free and model-based predictions in proportions matching those that best explained choice behavior. These results challenge the notion of a separate model-free learner and suggest a more integrated computational architecture for high-level human decision-making. PMID:21435563

Emmetropisation and the aetiology of refractive errors

PubMed Central

Flitcroft, D I

2014-01-01

The distribution of human refractive errors displays features that are not commonly seen in other biological variables. Compared with the more typical Gaussian distribution, adult refraction within a population typically has a negative skew and increased kurtosis (ie is leptokurtotic). This distribution arises from two apparently conflicting tendencies, first, the existence of a mechanism to control eye growth during infancy so as to bring refraction towards emmetropia/low hyperopia (ie emmetropisation) and second, the tendency of many human populations to develop myopia during later childhood and into adulthood. The distribution of refraction therefore changes significantly with age. Analysis of the processes involved in shaping refractive development allows for the creation of a life course model of refractive development. Monte Carlo simulations based on such a model can recreate the variation of refractive distributions seen from birth to adulthood and the impact of increasing myopia prevalence on refractive error distributions in Asia. PMID:24406411

Comparison of Procedures for Dual and Triple Closely Spaced Parallel Runways

NASA Technical Reports Server (NTRS)

Verma, Savita; Ballinger, Deborah; Subramanian Shobana; Kozon, Thomas

2012-01-01

A human-in-the-loop high fidelity flight simulation experiment was conducted, which investigated and compared breakout procedures for Very Closely Spaced Parallel Approaches (VCSPA) with two and three runways. To understand the feasibility, usability and human factors of two and three runway VCSPA, data were collected and analyzed on the dependent variables of breakout cross track error and pilot workload. Independent variables included number of runways, cause of breakout and location of breakout. Results indicated larger cross track error and higher workload using three runways as compared to 2-runway operations. Significant interaction effects involving breakout cause and breakout location were also observed. Across all conditions, cross track error values showed high levels of breakout trajectory accuracy and pilot workload remained manageable. Results suggest possible avenues of future adaptation for adopting these procedures (e.g., pilot training), while also showing potential promise of the concept.

Cognition in Space Workshop. 1; Metrics and Models

NASA Technical Reports Server (NTRS)

Woolford, Barbara; Fielder, Edna

2005-01-01

"Cognition in Space Workshop I: Metrics and Models" was the first in a series of workshops sponsored by NASA to develop an integrated research and development plan supporting human cognition in space exploration. The workshop was held in Chandler, Arizona, October 25-27, 2004. The participants represented academia, government agencies, and medical centers. This workshop addressed the following goal of the NASA Human System Integration Program for Exploration: to develop a program to manage risks due to human performance and human error, specifically ones tied to cognition. Risks range from catastrophic error to degradation of efficiency and failure to accomplish mission goals. Cognition itself includes memory, decision making, initiation of motor responses, sensation, and perception. Four subgoals were also defined at the workshop as follows: (1) NASA needs to develop a human-centered design process that incorporates standards for human cognition, human performance, and assessment of human interfaces; (2) NASA needs to identify and assess factors that increase risks associated with cognition; (3) NASA needs to predict risks associated with cognition; and (4) NASA needs to mitigate risk, both prior to actual missions and in real time. This report develops the material relating to these four subgoals.

Task Decomposition in Human Reliability Analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Boring, Ronald Laurids; Joe, Jeffrey Clark

2014-06-01

In the probabilistic safety assessments (PSAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally, both approachesmore » should arrive at the same set of HFEs. This question remains central as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PSAs tend to be top-down— defined as a subset of the PSA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) are more likely to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications.« less

Latent error detection: A golden two hours for detection.

PubMed

Saward, Justin R E; Stanton, Neville A

2017-03-01

Undetected error in safety critical contexts generates a latent condition that can contribute to a future safety failure. The detection of latent errors post-task completion is observed in naval air engineers using a diary to record work-related latent error detection (LED) events. A systems view is combined with multi-process theories to explore sociotechnical factors associated with LED. Perception of cues in different environments facilitates successful LED, for which the deliberate review of past tasks within two hours of the error occurring and whilst remaining in the same or similar sociotechnical environment to that which the error occurred appears most effective. Identified ergonomic interventions offer potential mitigation for latent errors; particularly in simple everyday habitual tasks. It is thought safety critical organisations should look to engineer further resilience through the application of LED techniques that engage with system cues across the entire sociotechnical environment, rather than relying on consistent human performance. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

Understanding diagnostic errors in medicine: a lesson from aviation

PubMed Central

Singh, H; Petersen, L A; Thomas, E J

2006-01-01

The impact of diagnostic errors on patient safety in medicine is increasingly being recognized. Despite the current progress in patient safety research, the understanding of such errors and how to prevent them is inadequate. Preliminary research suggests that diagnostic errors have both cognitive and systems origins. Situational awareness is a model that is primarily used in aviation human factors research that can encompass both the cognitive and the systems roots of such errors. This conceptual model offers a unique perspective in the study of diagnostic errors. The applicability of this model is illustrated by the analysis of a patient whose diagnosis of spinal cord compression was substantially delayed. We suggest how the application of this framework could lead to potential areas of intervention and outline some areas of future research. It is possible that the use of such a model in medicine could help reduce errors in diagnosis and lead to significant improvements in patient care. Further research is needed, including the measurement of situational awareness and correlation with health outcomes. PMID:16751463

At least some errors are randomly generated (Freud was wrong)

NASA Technical Reports Server (NTRS)

Sellen, A. J.; Senders, J. W.

1986-01-01

An experiment was carried out to expose something about human error generating mechanisms. In the context of the experiment, an error was made when a subject pressed the wrong key on a computer keyboard or pressed no key at all in the time allotted. These might be considered, respectively, errors of substitution and errors of omission. Each of seven subjects saw a sequence of three digital numbers, made an easily learned binary judgement about each, and was to press the appropriate one of two keys. Each session consisted of 1,000 presentations of randomly permuted, fixed numbers broken into 10 blocks of 100. One of two keys should have been pressed within one second of the onset of each stimulus. These data were subjected to statistical analyses in order to probe the nature of the error generating mechanisms. Goodness of fit tests for a Poisson distribution for the number of errors per 50 trial interval and for an exponential distribution of the length of the intervals between errors were carried out. There is evidence for an endogenous mechanism that may best be described as a random error generator. Furthermore, an item analysis of the number of errors produced per stimulus suggests the existence of a second mechanism operating on task driven factors producing exogenous errors. Some errors, at least, are the result of constant probability generating mechanisms with error rate idiosyncratically determined for each subject.

Alteration of a motor learning rule under mirror-reversal transformation does not depend on the amplitude of visual error.

PubMed

Kasuga, Shoko; Kurata, Makiko; Liu, Meigen; Ushiba, Junichi

2015-05-01

Human's sophisticated motor learning system paradoxically interferes with motor performance when visual information is mirror-reversed (MR), because normal movement error correction further aggravates the error. This error-increasing mechanism makes performing even a simple reaching task difficult, but is overcome by alterations in the error correction rule during the trials. To isolate factors that trigger learners to change the error correction rule, we manipulated the gain of visual angular errors when participants made arm-reaching movements with mirror-reversed visual feedback, and compared the rule alteration timing between groups with normal or reduced gain. Trial-by-trial changes in the visual angular error was tracked to explain the timing of the change in the error correction rule. Under both gain conditions, visual angular errors increased under the MR transformation, and suddenly decreased after 3-5 trials with increase. The increase became degressive at different amplitude between the two groups, nearly proportional to the visual gain. The findings suggest that the alteration of the error-correction rule is not dependent on the amplitude of visual angular errors, and possibly determined by the number of trials over which the errors increased or statistical property of the environment. The current results encourage future intensive studies focusing on the exact rule-change mechanism. Copyright © 2014 Elsevier Ireland Ltd and the Japan Neuroscience Society. All rights reserved.

Effect of contrast on human speed perception

NASA Technical Reports Server (NTRS)

Stone, Leland S.; Thompson, Peter

1992-01-01

This study is part of an ongoing collaborative research effort between the Life Science and Human Factors Divisions at NASA ARC to measure the accuracy of human motion perception in order to predict potential errors in human perception/performance and to facilitate the design of display systems that minimize the effects of such deficits. The study describes how contrast manipulations can produce significant errors in human speed perception. Specifically, when two simultaneously presented parallel gratings are moving at the same speed within stationary windows, the lower-contrast grating appears to move more slowly. This contrast-induced misperception of relative speed is evident across a wide range of contrasts (2.5-50 percent) and does not appear to saturate (e.g., a 50 percent contrast grating appears slower than a 70 percent contrast grating moving at the same speed). The misperception is large: a 70 percent contrast grating must, on average, be slowed by 35 percent to match a 10 percent contrast grating moving at 2 deg/sec (N = 6). Furthermore, it is largely independent of the absolute contrast level and is a quasilinear function of log contrast ratio. A preliminary parametric study shows that, although spatial frequency has little effect, the relative orientation of the two gratings is important. Finally, the effect depends on the temporal presentation of the stimuli: the effects of contrast on perceived speed appears lessened when the stimuli to be matched are presented sequentially. These data constrain both physiological models of visual cortex and models of human performance. We conclude that viewing conditions that effect contrast, such as fog, may cause significant errors in speed judgments.

21 CFR 1040.11 - Specific purpose laser products.

Code of Federal Regulations, 2011 CFR

2011-04-01

... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of... 1040.11 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...

21 CFR 1040.11 - Specific purpose laser products.

Code of Federal Regulations, 2010 CFR

2010-04-01

... radiation intended for irradiation of the human body. Such means may have an error in measurement of no more... IIIa; and (ii) Used for relative positioning of the human body; and (iii) Not used for irradiation of... 1040.11 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED...

Incidence of patient safety events and process-related human failures during intra-hospital transportation of patients: retrospective exploration from the institutional incident reporting system.

PubMed

Yang, Shu-Hui; Jerng, Jih-Shuin; Chen, Li-Chin; Li, Yu-Tsu; Huang, Hsiao-Fang; Wu, Chao-Ling; Chan, Jing-Yuan; Huang, Szu-Fen; Liang, Huey-Wen; Sun, Jui-Sheng

2017-11-03

Intra-hospital transportation (IHT) might compromise patient safety because of different care settings and higher demand on the human operation. Reports regarding the incidence of IHT-related patient safety events and human failures remain limited. To perform a retrospective analysis of IHT-related events, human failures and unsafe acts. A hospital-wide process for the IHT and database from the incident reporting system in a medical centre in Taiwan. All eligible IHT-related patient safety events between January 2010 to December 2015 were included. Incidence rate of IHT-related patient safety events, human failure modes, and types of unsafe acts. There were 206 patient safety events in 2 009 013 IHT sessions (102.5 per 1 000 000 sessions). Most events (n=148, 71.8%) did not involve patient harm, and process events (n=146, 70.9%) were most common. Events at the location of arrival (n=101, 49.0%) were most frequent; this location accounted for 61.0% and 44.2% of events with patient harm and those without harm, respectively (p<0.001). Of the events with human failures (n=186), the most common related process step was the preparation of the transportation team (n=91, 48.9%). Contributing unsafe acts included perceptual errors (n=14, 7.5%), decision errors (n=56, 30.1%), skill-based errors (n=48, 25.8%), and non-compliance (n=68, 36.6%). Multivariate analysis showed that human failure found in the arrival and hand-off sub-process (OR 4.84, p<0.001) was associated with increased patient harm, whereas the presence of omission (OR 0.12, p<0.001) was associated with less patient harm. This study shows a need to reduce human failures to prevent patient harm during intra-hospital transportation. We suggest that the transportation team pay specific attention to the sub-process at the location of arrival and prevent errors other than omissions. Long-term monitoring of IHT-related events is also warranted. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Aviation safety and automation technology for subsonic transports

NASA Technical Reports Server (NTRS)

Albers, James A.

1991-01-01

Discussed here are aviation safety human factors and air traffic control (ATC) automation research conducted at the NASA Ames Research Center. Research results are given in the areas of flight deck and ATC automations, displays and warning systems, crew coordination, and crew fatigue and jet lag. Accident investigation and an incident reporting system that is used to guide the human factors research is discussed. A design philosophy for human-centered automation is given, along with an evaluation of automation on advanced technology transports. Intelligent error tolerant systems such as electronic checklists are discussed along with design guidelines for reducing procedure errors. The data on evaluation of Crew Resource Management (CRM) training indicates highly significant positive changes in appropriate flight deck behavior and more effective use of available resources for crew members receiving the training.

Children perseverate to a human's actions but not to a robot's actions.

PubMed

Moriguchi, Yusuke; Kanda, Takayuki; Ishiguro, Hiroshi; Itakura, Shoji

2010-01-01

Previous research has shown that young children commit perseverative errors from their observation of another person's actions. The present study examined how social observation would lead children to perseverative tendencies, using a robot. In Experiment 1, preschoolers watched either a human model or a robot sorting cards according to one dimension (e.g. shape), after which they were asked to sort according to a different dimension (e.g. colour). The results showed that children's behaviours in the task were significantly influenced by the human model's actions but not by the robot's actions. Experiment 2 excluded the possibility that children's behaviours were not affected by the robot's actions because they did not observe its actions. We concluded that children's perseverative errors from social observation resulted, in part, from their socio-cognitive ability.

Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination.

PubMed

Mumma, Joel M; Durso, Francis T; Ferguson, Ashley N; Gipson, Christina L; Casanova, Lisa; Erukunuakpor, Kimberly; Kraft, Colleen S; Walsh, Victoria L; Zimring, Craig; DuBose, Jennifer; Jacob, Jesse T

2018-03-05

Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

Suffering in Silence: Medical Error and its Impact on Health Care Providers.

PubMed

Robertson, Jennifer J; Long, Brit

2018-04-01

All humans are fallible. Because physicians are human, unintentional errors unfortunately occur. While unintentional medical errors have an impact on patients and their families, they may also contribute to adverse mental and emotional effects on the involved provider(s). These may include burnout, lack of concentration, poor work performance, posttraumatic stress disorder, depression, and even suicidality. The objectives of this article are to 1) discuss the impact medical error has on involved provider(s), 2) provide potential reasons why medical error can have a negative impact on provider mental health, and 3) suggest solutions for providers and health care organizations to recognize and mitigate the adverse effects medical error has on providers. Physicians and other providers may feel a variety of adverse emotions after medical error, including guilt, shame, anxiety, fear, and depression. It is thought that the pervasive culture of perfectionism and individual blame in medicine plays a considerable role toward these negative effects. In addition, studies have found that despite physicians' desire for support after medical error, many physicians feel a lack of personal and administrative support. This may further contribute to poor emotional well-being. Potential solutions in the literature are proposed, including provider counseling, learning from mistakes without fear of punishment, discussing mistakes with others, focusing on the system versus the individual, and emphasizing provider wellness. Much of the reviewed literature is limited in terms of an emergency medicine focus or even regarding physicians in general. In addition, most studies are survey- or interview-based, which limits objectivity. While additional, more objective research is needed in terms of mitigating the effects of error on physicians, this review may help provide insight and support for those who feel alone in their attempt to heal after being involved in an adverse medical event. Unintentional medical error will likely always be a part of the medical system. However, by focusing on provider as well as patient health, we may be able to foster resilience in providers and improve care for patients in healthy, safe, and constructive environments. Copyright © 2017 Elsevier Inc. All rights reserved.

Investigation of technology needs for avoiding helicopter pilot error related accidents

NASA Technical Reports Server (NTRS)

Chais, R. I.; Simpson, W. E.

1985-01-01

Pilot error which is cited as a cause or related factor in most rotorcraft accidents was examined. Pilot error related accidents in helicopters to identify areas in which new technology could reduce or eliminate the underlying causes of these human errors were investigated. The aircraft accident data base at the U.S. Army Safety Center was studied as the source of data on helicopter accidents. A randomly selected sample of 110 aircraft records were analyzed on a case-by-case basis to assess the nature of problems which need to be resolved and applicable technology implications. Six technology areas in which there appears to be a need for new or increased emphasis are identified.

Misrepresentations of evolutionary psychology in sex and gender textbooks.

PubMed

Winegard, Benjamin M; Winegard, Bo M; Deaner, Robert O

2014-05-20

Evolutionary psychology has provoked controversy, especially when applied to human sex differences. We hypothesize that this is partly due to misunderstandings of evolutionary psychology that are perpetuated by undergraduate sex and gender textbooks. As an initial test of this hypothesis, we develop a catalog of eight types of errors and document their occurrence in 15 widely used sex and gender textbooks. Consistent with our hypothesis, of the 12 textbooks that discussed evolutionary psychology, all contained at least one error, and the median number of errors was five. The most common types of errors were "Straw Man," "Biological Determinism," and "Species Selection." We conclude by suggesting improvements to undergraduate sex and gender textbooks.

Error reduction, patient safety and institutional ethics committees.

PubMed

Meaney, Mark E

2004-01-01

Institutional ethics committees remain largely absent from the literature on error reduction and patient safety. In this paper, the author endeavors to fill the gap. As noted in the Hastings Center's recent report, "Promoting Patient Safety," the occurrence of medical error involves complex web of multiple factors. Human misstep is certainly one such factor, but not the only one. This paper builds on the Hastings Center's report in arguing that institutional ethics committees ought to play an integral role in the transformation of a "culture of blame" to a "culture of safety" in healthcare delivery.

Top-down and bottom-up definitions of human failure events in human reliability analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Boring, Ronald Laurids

2014-10-01

In the probabilistic risk assessments (PRAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally, both approachesmore » should arrive at the same set of HFEs. This question is crucial, however, as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PRAs tend to be top-down—defined as a subset of the PRA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) often tend to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications.« less

Deep Networks Can Resemble Human Feed-forward Vision in Invariant Object Recognition

PubMed Central

Kheradpisheh, Saeed Reza; Ghodrati, Masoud; Ganjtabesh, Mohammad; Masquelier, Timothée

2016-01-01

Deep convolutional neural networks (DCNNs) have attracted much attention recently, and have shown to be able to recognize thousands of object categories in natural image databases. Their architecture is somewhat similar to that of the human visual system: both use restricted receptive fields, and a hierarchy of layers which progressively extract more and more abstracted features. Yet it is unknown whether DCNNs match human performance at the task of view-invariant object recognition, whether they make similar errors and use similar representations for this task, and whether the answers depend on the magnitude of the viewpoint variations. To investigate these issues, we benchmarked eight state-of-the-art DCNNs, the HMAX model, and a baseline shallow model and compared their results to those of humans with backward masking. Unlike in all previous DCNN studies, we carefully controlled the magnitude of the viewpoint variations to demonstrate that shallow nets can outperform deep nets and humans when variations are weak. When facing larger variations, however, more layers were needed to match human performance and error distributions, and to have representations that are consistent with human behavior. A very deep net with 18 layers even outperformed humans at the highest variation level, using the most human-like representations. PMID:27601096

Prediction of Foreign Object Debris/Damage type based in human factors for aeronautics using logistic regression model

NASA Astrophysics Data System (ADS)

Romo, David Ricardo

Foreign Object Debris/Damage (FOD) has been an issue for military and commercial aircraft manufacturers since the early ages of aviation and aerospace. Currently, aerospace is growing rapidly and the chances of FOD presence are growing as well. One of the principal causes in manufacturing is the human error. The cost associated with human error in commercial and military aircrafts is approximately accountable for 4 billion dollars per year. This problem is currently addressed with prevention programs, elimination techniques, and designation of FOD areas, controlled access, restrictions of personal items entering designated areas, tool accountability, and the use of technology such as Radio Frequency Identification (RFID) tags, etc. All of the efforts mentioned before, have not show a significant occurrence reduction in terms of manufacturing processes. On the contrary, a repetitive path of occurrence is present, and the cost associated has not declined in a significant manner. In order to address the problem, this thesis proposes a new approach using statistical analysis. The effort of this thesis is to create a predictive model using historical categorical data from an aircraft manufacturer only focusing in human error causes. The use of contingency tables, natural logarithm of the odds and probability transformation is used in order to provide the predicted probabilities of each aircraft. A case of study is shown in this thesis in order to show the applied methodology. As a result, this approach is able to predict the possible outcomes of FOD by the workstation/area needed, and monthly predictions per workstation. This thesis is intended to be the starting point of statistical data analysis regarding FOD in human factors. The purpose of this thesis is to identify the areas where human error is the primary cause of FOD occurrence in order to design and implement accurate solutions. The advantages of the proposed methodology can go from the reduction of cost production, quality issues, repair cost, and assembly process time. Finally, a more reliable process is achieved, and the proposed methodology may be used in other aircrafts.

Dynamic Simulation of Human Gait Model With Predictive Capability.

PubMed

Sun, Jinming; Wu, Shaoli; Voglewede, Philip A

2018-03-01

In this paper, it is proposed that the central nervous system (CNS) controls human gait using a predictive control approach in conjunction with classical feedback control instead of exclusive classical feedback control theory that controls based on past error. To validate this proposition, a dynamic model of human gait is developed using a novel predictive approach to investigate the principles of the CNS. The model developed includes two parts: a plant model that represents the dynamics of human gait and a controller that represents the CNS. The plant model is a seven-segment, six-joint model that has nine degrees-of-freedom (DOF). The plant model is validated using data collected from able-bodied human subjects. The proposed controller utilizes model predictive control (MPC). MPC uses an internal model to predict the output in advance, compare the predicted output to the reference, and optimize the control input so that the predicted error is minimal. To decrease the complexity of the model, two joints are controlled using a proportional-derivative (PD) controller. The developed predictive human gait model is validated by simulating able-bodied human gait. The simulation results show that the developed model is able to simulate the kinematic output close to experimental data.

HUMAN EYE OPTICS: Determination of positions of optical elements of the human eye

NASA Astrophysics Data System (ADS)

Galetskii, S. O.; Cherezova, T. Yu

2009-02-01

An original method for noninvasive determining the positions of elements of intraocular optics is proposed. The analytic dependence of the measurement error on the optical-scheme parameters and the restriction in distance from the element being measured are determined within the framework of the method proposed. It is shown that the method can be efficiently used for determining the position of elements in the classical Gullstrand eye model and personalised eye models. The positions of six optical surfaces of the Gullstrand eye model and four optical surfaces of the personalised eye model can be determined with an error of less than 0.25 mm.

Evaluation and statistical inference for human connectomes.

PubMed

Pestilli, Franco; Yeatman, Jason D; Rokem, Ariel; Kay, Kendrick N; Wandell, Brian A

2014-10-01

Diffusion-weighted imaging coupled with tractography is currently the only method for in vivo mapping of human white-matter fascicles. Tractography takes diffusion measurements as input and produces the connectome, a large collection of white-matter fascicles, as output. We introduce a method to evaluate the evidence supporting connectomes. Linear fascicle evaluation (LiFE) takes any connectome as input and predicts diffusion measurements as output, using the difference between the measured and predicted diffusion signals to quantify the prediction error. We use the prediction error to evaluate the evidence that supports the properties of the connectome, to compare tractography algorithms and to test hypotheses about tracts and connections.

'Systemic Failures' and 'Human Error' in Canadian TSB Aviation Reports Between 1996 and 2002

NASA Technical Reports Server (NTRS)

Holloway, C. M.; Johnson, C. W.

2004-01-01

This paper describes the results of an independent analysis of the primary and contributory causes of aviation accidents in Canada between 1996 and 2003. The purpose of the study was to assess the comparative frequency of a range of causal factors in the reporting of these adverse events. Our results suggest that the majority of these high consequence accidents were attributed to human error. A large number of reports also mentioned wider systemic issues, including the managerial and regulatory context of aviation operations. These issues are more likely to appear as contributory rather than primary causes in this set of accident reports.

Evaluation of optimal control type models for the human gunner in an Anti-Aircraft Artillery (AAA) system

NASA Technical Reports Server (NTRS)

Phatak, A. V.; Kessler, K. M.

1975-01-01

The selection of the structure of optimal control type models for the human gunner in an anti aircraft artillery system is considered. Several structures within the LQG framework may be formulated. Two basic types are considered: (1) kth derivative controllers; and (2) proportional integral derivative (P-I-D) controllers. It is shown that a suitable criterion for model structure determination can be based on the ensemble statistics of the tracking error. In the case when the ensemble tracking steady state error is zero, it is suggested that a P-I-D controller formulation be used in preference to the kth derivative controller.

Visual difference metric for realistic image synthesis

NASA Astrophysics Data System (ADS)

Bolin, Mark R.; Meyer, Gary W.

1999-05-01

An accurate and efficient model of human perception has been developed to control the placement of sample in a realistic image synthesis algorithm. Previous sampling techniques have sought to spread the error equally across the image plane. However, this approach neglects the fact that the renderings are intended to be displayed for a human observer. The human visual system has a varying sensitivity to error that is based upon the viewing context. This means that equivalent optical discrepancies can be very obvious in one situation and imperceptible in another. It is ultimately the perceptibility of this error that governs image quality and should be used as the basis of a sampling algorithm. This paper focuses on a simplified version of the Lubin Visual Discrimination Metric (VDM) that was developed for insertion into an image synthesis algorithm. The sampling VDM makes use of a Haar wavelet basis for the cortical transform and a less severe spatial pooling operation. The model was extended for color including the effects of chromatic aberration. Comparisons are made between the execution time and visual difference map for the original Lubin and simplified visual difference metrics. Results for the realistic image synthesis algorithm are also presented.

Modeling and Quantification of Team Performance in Human Reliability Analysis for Probabilistic Risk Assessment

DOE Office of Scientific and Technical Information (OSTI.GOV)

Jeffrey C. JOe; Ronald L. Boring

Probabilistic Risk Assessment (PRA) and Human Reliability Assessment (HRA) are important technical contributors to the United States (U.S.) Nuclear Regulatory Commission’s (NRC) risk-informed and performance based approach to regulating U.S. commercial nuclear activities. Furthermore, all currently operating commercial NPPs in the U.S. are required by federal regulation to be staffed with crews of operators. Yet, aspects of team performance are underspecified in most HRA methods that are widely used in the nuclear industry. There are a variety of "emergent" team cognition and teamwork errors (e.g., communication errors) that are 1) distinct from individual human errors, and 2) important to understandmore » from a PRA perspective. The lack of robust models or quantification of team performance is an issue that affects the accuracy and validity of HRA methods and models, leading to significant uncertainty in estimating HEPs. This paper describes research that has the objective to model and quantify team dynamics and teamwork within NPP control room crews for risk informed applications, thereby improving the technical basis of HRA, which improves the risk-informed approach the NRC uses to regulate the U.S. commercial nuclear industry.« less

Neural markers of errors as endophenotypes in neuropsychiatric disorders

PubMed Central

Manoach, Dara S.; Agam, Yigal

2013-01-01

Learning from errors is fundamental to adaptive human behavior. It requires detecting errors, evaluating what went wrong, and adjusting behavior accordingly. These dynamic adjustments are at the heart of behavioral flexibility and accumulating evidence suggests that deficient error processing contributes to maladaptively rigid and repetitive behavior in a range of neuropsychiatric disorders. Neuroimaging and electrophysiological studies reveal highly reliable neural markers of error processing. In this review, we evaluate the evidence that abnormalities in these neural markers can serve as sensitive endophenotypes of neuropsychiatric disorders. We describe the behavioral and neural hallmarks of error processing, their mediation by common genetic polymorphisms, and impairments in schizophrenia, obsessive-compulsive disorder, and autism spectrum disorders. We conclude that neural markers of errors meet several important criteria as endophenotypes including heritability, established neuroanatomical and neurochemical substrates, association with neuropsychiatric disorders, presence in syndromally-unaffected family members, and evidence of genetic mediation. Understanding the mechanisms of error processing deficits in neuropsychiatric disorders may provide novel neural and behavioral targets for treatment and sensitive surrogate markers of treatment response. Treating error processing deficits may improve functional outcome since error signals provide crucial information for flexible adaptation to changing environments. Given the dearth of effective interventions for cognitive deficits in neuropsychiatric disorders, this represents a potentially promising approach. PMID:23882201

Neurochemical enhancement of conscious error awareness.

PubMed

Hester, Robert; Nandam, L Sanjay; O'Connell, Redmond G; Wagner, Joe; Strudwick, Mark; Nathan, Pradeep J; Mattingley, Jason B; Bellgrove, Mark A

2012-02-22

How the brain monitors ongoing behavior for performance errors is a central question of cognitive neuroscience. Diminished awareness of performance errors limits the extent to which humans engage in corrective behavior and has been linked to loss of insight in a number of psychiatric syndromes (e.g., attention deficit hyperactivity disorder, drug addiction). These conditions share alterations in monoamine signaling that may influence the neural mechanisms underlying error processing, but our understanding of the neurochemical drivers of these processes is limited. We conducted a randomized, double-blind, placebo-controlled, cross-over design of the influence of methylphenidate, atomoxetine, and citalopram on error awareness in 27 healthy participants. The error awareness task, a go/no-go response inhibition paradigm, was administered to assess the influence of monoaminergic agents on performance errors during fMRI data acquisition. A single dose of methylphenidate, but not atomoxetine or citalopram, significantly improved the ability of healthy volunteers to consciously detect performance errors. Furthermore, this behavioral effect was associated with a strengthening of activation differences in the dorsal anterior cingulate cortex and inferior parietal lobe during the methylphenidate condition for errors made with versus without awareness. Our results have implications for the understanding of the neurochemical underpinnings of performance monitoring and for the pharmacological treatment of a range of disparate clinical conditions that are marked by poor awareness of errors.

An error taxonomy system for analysis of haemodialysis incidents.

PubMed

Gu, Xiuzhu; Itoh, Kenji; Suzuki, Satoshi

2014-12-01

This paper describes the development of a haemodialysis error taxonomy system for analysing incidents and predicting the safety status of a dialysis organisation. The error taxonomy system was developed by adapting an error taxonomy system which assumed no specific specialty to haemodialysis situations. Its application was conducted with 1,909 incident reports collected from two dialysis facilities in Japan. Over 70% of haemodialysis incidents were reported as problems or complications related to dialyser, circuit, medication and setting of dialysis condition. Approximately 70% of errors took place immediately before and after the four hours of haemodialysis therapy. Error types most frequently made in the dialysis unit were omission and qualitative errors. Failures or complications classified to staff human factors, communication, task and organisational factors were found in most dialysis incidents. Device/equipment/materials, medicine and clinical documents were most likely to be involved in errors. Haemodialysis nurses were involved in more incidents related to medicine and documents, whereas dialysis technologists made more errors with device/equipment/materials. This error taxonomy system is able to investigate incidents and adverse events occurring in the dialysis setting but is also able to estimate safety-related status of an organisation, such as reporting culture. © 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.

Neural markers of errors as endophenotypes in neuropsychiatric disorders.

PubMed

Manoach, Dara S; Agam, Yigal

2013-01-01

Learning from errors is fundamental to adaptive human behavior. It requires detecting errors, evaluating what went wrong, and adjusting behavior accordingly. These dynamic adjustments are at the heart of behavioral flexibility and accumulating evidence suggests that deficient error processing contributes to maladaptively rigid and repetitive behavior in a range of neuropsychiatric disorders. Neuroimaging and electrophysiological studies reveal highly reliable neural markers of error processing. In this review, we evaluate the evidence that abnormalities in these neural markers can serve as sensitive endophenotypes of neuropsychiatric disorders. We describe the behavioral and neural hallmarks of error processing, their mediation by common genetic polymorphisms, and impairments in schizophrenia, obsessive-compulsive disorder, and autism spectrum disorders. We conclude that neural markers of errors meet several important criteria as endophenotypes including heritability, established neuroanatomical and neurochemical substrates, association with neuropsychiatric disorders, presence in syndromally-unaffected family members, and evidence of genetic mediation. Understanding the mechanisms of error processing deficits in neuropsychiatric disorders may provide novel neural and behavioral targets for treatment and sensitive surrogate markers of treatment response. Treating error processing deficits may improve functional outcome since error signals provide crucial information for flexible adaptation to changing environments. Given the dearth of effective interventions for cognitive deficits in neuropsychiatric disorders, this represents a potentially promising approach.

Understanding reliance on automation: effects of error type, error distribution, age and experience

PubMed Central

Sanchez, Julian; Rogers, Wendy A.; Fisk, Arthur D.; Rovira, Ericka

2015-01-01

An obstacle detection task supported by “imperfect” automation was used with the goal of understanding the effects of automation error types and age on automation reliance. Sixty younger and sixty older adults interacted with a multi-task simulation of an agricultural vehicle (i.e. a virtual harvesting combine). The simulator included an obstacle detection task and a fully manual tracking task. A micro-level analysis provided insight into the way reliance patterns change over time. The results indicated that there are distinct patterns of reliance that develop as a function of error type. A prevalence of automation false alarms led participants to under-rely on the automation during alarm states while over relying on it during non-alarms states. Conversely, a prevalence of automation misses led participants to over-rely on automated alarms and under-rely on the automation during non-alarm states. Older adults adjusted their behavior according to the characteristics of the automation similarly to younger adults, although it took them longer to do so. The results of this study suggest the relationship between automation reliability and reliance depends on the prevalence of specific errors and on the state of the system. Understanding the effects of automation detection criterion settings on human-automation interaction can help designers of automated systems make predictions about human behavior and system performance as a function of the characteristics of the automation. PMID:25642142

Peripheral refraction and image blur in four meridians in emmetropes and myopes.

PubMed

Shen, Jie; Spors, Frank; Egan, Donald; Liu, Chunming

2018-01-01

The peripheral refractive error of the human eye has been hypothesized to be a major stimulus for the development of its central refractive error. The purpose of this study was to investigate the changes in the peripheral refractive error across horizontal, vertical and two diagonal meridians in emmetropic and low, moderate and high myopic adults. Thirty-four adult subjects were recruited and aberration was measured using a modified commercial aberrometer. We then computed the refractive error in power vector notation from second-order Zernike terms. Statistical analysis was performed to evaluate the statistical differences in refractive error profiles between the subject groups and across all measured visual field meridians. Small amounts of relative myopic shift were observed in emmetropic and low myopic subjects. However, moderate and high myopic subjects exhibited a relative hyperopic shift in all four meridians. Astigmatism J 0 and J 45 had quadratic or linear changes dependent on the visual field meridians. Peripheral Sphero-Cylindrical Retinal Image Blur increased in emmetropic eyes in most of the measured visual fields. The findings indicate an overall emmetropic or slightly relative myopic periphery (spherical or oblate retinal shape) formed in emmetropes and low myopes, while moderate and high myopes form relative hyperopic periphery (prolate, or less oblate, retinal shape). In general, human emmetropic eyes demonstrate higher amount of peripheral retinal image blur.

Complications: acknowledging, managing, and coping with human error.

PubMed

Helo, Sevann; Moulton, Carol-Anne E

2017-08-01

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

Understanding reliance on automation: effects of error type, error distribution, age and experience.

PubMed

Sanchez, Julian; Rogers, Wendy A; Fisk, Arthur D; Rovira, Ericka

2014-03-01

An obstacle detection task supported by "imperfect" automation was used with the goal of understanding the effects of automation error types and age on automation reliance. Sixty younger and sixty older adults interacted with a multi-task simulation of an agricultural vehicle (i.e. a virtual harvesting combine). The simulator included an obstacle detection task and a fully manual tracking task. A micro-level analysis provided insight into the way reliance patterns change over time. The results indicated that there are distinct patterns of reliance that develop as a function of error type. A prevalence of automation false alarms led participants to under-rely on the automation during alarm states while over relying on it during non-alarms states. Conversely, a prevalence of automation misses led participants to over-rely on automated alarms and under-rely on the automation during non-alarm states. Older adults adjusted their behavior according to the characteristics of the automation similarly to younger adults, although it took them longer to do so. The results of this study suggest the relationship between automation reliability and reliance depends on the prevalence of specific errors and on the state of the system. Understanding the effects of automation detection criterion settings on human-automation interaction can help designers of automated systems make predictions about human behavior and system performance as a function of the characteristics of the automation.

Complications: acknowledging, managing, and coping with human error

PubMed Central

Moulton, Carol-Anne E.

2017-01-01

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions. PMID:28904910

Method and Apparatus for Evaluating the Visual Quality of Processed Digital Video Sequences

NASA Technical Reports Server (NTRS)

Watson, Andrew B. (Inventor)

2002-01-01

A Digital Video Quality (DVQ) apparatus and method that incorporate a model of human visual sensitivity to predict the visibility of artifacts. The DVQ method and apparatus are used for the evaluation of the visual quality of processed digital video sequences and for adaptively controlling the bit rate of the processed digital video sequences without compromising the visual quality. The DVQ apparatus minimizes the required amount of memory and computation. The input to the DVQ apparatus is a pair of color image sequences: an original (R) non-compressed sequence, and a processed (T) sequence. Both sequences (R) and (T) are sampled, cropped, and subjected to color transformations. The sequences are then subjected to blocking and discrete cosine transformation, and the results are transformed to local contrast. The next step is a time filtering operation which implements the human sensitivity to different time frequencies. The results are converted to threshold units by dividing each discrete cosine transform coefficient by its respective visual threshold. At the next stage the two sequences are subtracted to produce an error sequence. The error sequence is subjected to a contrast masking operation, which also depends upon the reference sequence (R). The masked errors can be pooled in various ways to illustrate the perceptual error over various dimensions, and the pooled error can be converted to a visual quality measure.

[What Surgeons Should Know about Risk Management].

PubMed

Strametz, R; Tannheimer, M; Rall, M

2017-02-01

Background: The fact that medical treatment is associated with errors has long been recognized. Based on the principle of "first do no harm", numerous efforts have since been made to prevent such errors or limit their impact. However, recent statistics show that these measures do not sufficiently prevent grave mistakes with serious consequences. Preventable mistakes such as wrong patient or wrong site surgery still frequently occur in error statistics. Methods: Based on insight from research on human error, in due consideration of recent legislative regulations in Germany, the authors give an overview of the clinical risk management tools needed to identify risks in surgery, analyse their causes, and determine adequate measures to manage those risks depending on their relevance. The use and limitations of critical incident reporting systems (CIRS), safety checklists and crisis resource management (CRM) are highlighted. Also the rationale for IT systems to support the risk management process is addressed. Results/Conclusion: No single tool of risk management can be effective as a standalone instrument, but unfolds its effect only when embedded in a superordinate risk management system, which integrates tailor-made elements to increase patient safety into the workflows of each organisation. Competence in choosing adequate tools, effective IT systems to support the risk management process as well as leadership and commitment to constructive handling of human error are crucial components to establish a safety culture in surgery. Georg Thieme Verlag KG Stuttgart · New York.

A Framework for Human Microbiome Research

DTIC Science & Technology

2012-06-14

determined that many compo- nents of data production and processing can contribute errors and artefacts. We investigated methods that avoid these errors and...protocol that ensured consistency in the high-throughput production . To maximize accuracy and consistency, protocols were evaluated primarily using a...future benefits, this resource may promote the development of novel prophylactic strategies such as the application of prebiotics and probiotics to

5 CFR 839.301 - What should I do if I am not sure whether I am or was in the wrong retirement plan?

Code of Federal Regulations, 2010 CFR

2010-01-01

... ERRORS UNDER THE FEDERAL ERRONEOUS RETIREMENT COVERAGE CORRECTIONS ACT Employer Responsibility to Notify...) If you are an employee, your employer has your personnel records and will review them to determine whether an error has been made. Therefore, you should notify your employer's human resources office if you...

Effect of Job Satisfaction and Motivation towards Employee's Performance in XYZ Shipping Company

ERIC Educational Resources Information Center

Octaviannand, Ramona; Pandjaitan, Nurmala K.; Kuswanto, Sadikin

2017-01-01

In the digital and globalization era which are demanding for tech progress. Human resources need to work more closely and concentration. Small errors can lead to fatal errors that result in high costs for the company. The loss of motivation at work influences employee satisfaction and have a negative impact on employee performance. Research was…

Mapping the Origins of Time: Scalar Errors in Infant Time Estimation

ERIC Educational Resources Information Center

Addyman, Caspar; Rocha, Sinead; Mareschal, Denis

2014-01-01

Time is central to any understanding of the world. In adults, estimation errors grow linearly with the length of the interval, much faster than would be expected of a clock-like mechanism. Here we present the first direct demonstration that this is also true in human infants. Using an eye-tracking paradigm, we examined 4-, 6-, 10-, and…

The Effect of Teacher Error Feedback on the Accuracy of EFL Student Writing

ERIC Educational Resources Information Center

Pan, Yi-chun

2010-01-01

This study investigated the effect of teacher error feedback on students' ability to write accurately. Three male first-year Physics graduate students at a university in Taiwan participated in this study. They were asked to write a 100-word passage about the greatest invention in human history. Within days of the teacher's grammatical feedback,…

Color filter array design based on a human visual model

NASA Astrophysics Data System (ADS)

Parmar, Manu; Reeves, Stanley J.

2004-05-01

To reduce cost and complexity associated with registering multiple color sensors, most consumer digital color cameras employ a single sensor. A mosaic of color filters is overlaid on a sensor array such that only one color channel is sampled per pixel location. The missing color values must be reconstructed from available data before the image is displayed. The quality of the reconstructed image depends fundamentally on the array pattern and the reconstruction technique. We present a design method for color filter array patterns that use red, green, and blue color channels in an RGB array. A model of the human visual response for luminance and opponent chrominance channels is used to characterize the perceptual error between a fully sampled and a reconstructed sparsely-sampled image. Demosaicking is accomplished using Wiener reconstruction. To ensure that the error criterion reflects perceptual effects, reconstruction is done in a perceptually uniform color space. A sequential backward selection algorithm is used to optimize the error criterion to obtain the sampling arrangement. Two different types of array patterns are designed: non-periodic and periodic arrays. The resulting array patterns outperform commonly used color filter arrays in terms of the error criterion.

Effects of auditory radio interference on a fine, continuous, open motor skill.

PubMed

Lazar, J M; Koceja, D M; Morris, H H

1995-06-01

The effects of human speech on a fine, continuous, and open motor skill were examined. A tape of auditory human radio traffic was injected into a tank gunnery simulator during each training session for 4 wk. of training for 3 hr. a week. The dependent variables were identification time, fire time, kill time, systems errors, and acquisition errors. These were measured by the Unit Conduct Of Fire Trainer (UCOFT). The interference was interjected into the UCOFT Tank Table VIII gunnery test. A Solomon four-group design was used. A 2 x 2 analysis of variance was used to assess whether interference gunnery training resulted in improvements in interference posttest scores. During the first three weeks of training, the interference group committed 106% more systems errors and 75% more acquisition errors than the standard group. The interference training condition was associated with a significant improvement from pre- to posttest of 44% in over-all UCOFT scores; however, when examined on the posttest the standard training did not improve performance significantly over the same period. It was concluded that auditory radio interference degrades performance of this fine, continuous, open motor skill, and interference training appears to abate the effects of this degradation.

Using a Hybrid Model to Forecast the Prevalence of Schistosomiasis in Humans.

PubMed

Zhou, Lingling; Xia, Jing; Yu, Lijing; Wang, Ying; Shi, Yun; Cai, Shunxiang; Nie, Shaofa

2016-03-23

We previously proposed a hybrid model combining both the autoregressive integrated moving average (ARIMA) and the nonlinear autoregressive neural network (NARNN) models in forecasting schistosomiasis. Our purpose in the current study was to forecast the annual prevalence of human schistosomiasis in Yangxin County, using our ARIMA-NARNN model, thereby further certifying the reliability of our hybrid model. We used the ARIMA, NARNN and ARIMA-NARNN models to fit and forecast the annual prevalence of schistosomiasis. The modeling time range included was the annual prevalence from 1956 to 2008 while the testing time range included was from 2009 to 2012. The mean square error (MSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) were used to measure the model performance. We reconstructed the hybrid model to forecast the annual prevalence from 2013 to 2016. The modeling and testing errors generated by the ARIMA-NARNN model were lower than those obtained from either the single ARIMA or NARNN models. The predicted annual prevalence from 2013 to 2016 demonstrated an initial decreasing trend, followed by an increase. The ARIMA-NARNN model can be well applied to analyze surveillance data for early warning systems for the control and elimination of schistosomiasis.

Automated Identification of Abnormal Adult EEGs

PubMed Central

López, S.; Suarez, G.; Jungreis, D.; Obeid, I.; Picone, J.

2016-01-01

The interpretation of electroencephalograms (EEGs) is a process that is still dependent on the subjective analysis of the examiners. Though interrater agreement on critical events such as seizures is high, it is much lower on subtler events (e.g., when there are benign variants). The process used by an expert to interpret an EEG is quite subjective and hard to replicate by machine. The performance of machine learning technology is far from human performance. We have been developing an interpretation system, AutoEEG, with a goal of exceeding human performance on this task. In this work, we are focusing on one of the early decisions made in this process – whether an EEG is normal or abnormal. We explore two baseline classification algorithms: k-Nearest Neighbor (kNN) and Random Forest Ensemble Learning (RF). A subset of the TUH EEG Corpus was used to evaluate performance. Principal Components Analysis (PCA) was used to reduce the dimensionality of the data. kNN achieved a 41.8% detection error rate while RF achieved an error rate of 31.7%. These error rates are significantly lower than those obtained by random guessing based on priors (49.5%). The majority of the errors were related to misclassification of normal EEGs. PMID:27195311

Estimation of Human Body Volume (BV) from Anthropometric Measurements Based on Three-Dimensional (3D) Scan Technique.

PubMed

Liu, Xingguo; Niu, Jianwei; Ran, Linghua; Liu, Taijie

2017-08-01

This study aimed to develop estimation formulae for the total human body volume (BV) of adult males using anthropometric measurements based on a three-dimensional (3D) scanning technique. Noninvasive and reliable methods to predict the total BV from anthropometric measurements based on a 3D scan technique were addressed in detail. A regression analysis of BV based on four key measurements was conducted for approximately 160 adult male subjects. Eight total models of human BV show that the predicted results fitted by the regression models were highly correlated with the actual BV (p < 0.001). Two metrics, the mean value of the absolute difference between the actual and predicted BV (V error ) and the mean value of the ratio between V error and actual BV (RV error ), were calculated. The linear model based on human weight was recommended as the most optimal due to its simplicity and high efficiency. The proposed estimation formulae are valuable for estimating total body volume in circumstances in which traditional underwater weighing or air displacement plethysmography is not applicable or accessible. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Human error and crew resource management failures in Naval aviation mishaps: a review of U.S. Naval Safety Center data, 1990-96.

PubMed

Wiegmann, D A; Shappell, S A

1999-12-01

The present study examined the role of human error and crew-resource management (CRM) failures in U.S. Naval aviation mishaps. All tactical jet (TACAIR) and rotary wing Class A flight mishaps between fiscal years 1990-1996 were reviewed. Results indicated that over 75% of both TACAIR and rotary wing mishaps were attributable, at least in part, to some form of human error of which 70% were associated with aircrew human factors. Of these aircrew-related mishaps, approximately 56% involved at least one CRM failure. These percentages are very similar to those observed prior to the implementation of aircrew coordination training (ACT) in the fleet, suggesting that the initial benefits of the program have not persisted and that CRM failures continue to plague Naval aviation. Closer examination of these CRM-related mishaps suggest that the type of flight operations (preflight, routine, emergency) do play a role in the etiology of CRM failures. A larger percentage of CRM failures occurred during non-routine or extremis flight situations when TACAIR mishaps were considered. In contrast, a larger percentage of rotary wing CRM mishaps involved failures that occurred during routine flight operations. These findings illustrate the complex etiology of CRM failures within Naval aviation and support the need for ACT programs tailored to the unique problems faced by specific communities in the fleet.

The effects of wildfire prevention activities

Treesearch

Douglas Thomas; David Butry; Jeffrey Prestemon

2013-01-01

Eighty percent of wildfires are human caused. Unintentional human-caused fires can be caused by carelessness, failure of equipment, or a number of other factors. A significant proportion of the literature on accidents, in general, focuses on occupational accidents. Approximately 80 % to 90 % of these accidents are thought to be due to human error (Heinrich et al 1980...

An error analysis perspective for patient alignment systems.

PubMed

Figl, Michael; Kaar, Marcus; Hoffman, Rainer; Kratochwil, Alfred; Hummel, Johann

2013-09-01

This paper analyses the effects of error sources which can be found in patient alignment systems. As an example, an ultrasound (US) repositioning system and its transformation chain are assessed. The findings of this concept can also be applied to any navigation system. In a first step, all error sources were identified and where applicable, corresponding target registration errors were computed. By applying error propagation calculations on these commonly used registration/calibration and tracking errors, we were able to analyse the components of the overall error. Furthermore, we defined a special situation where the whole registration chain reduces to the error caused by the tracking system. Additionally, we used a phantom to evaluate the errors arising from the image-to-image registration procedure, depending on the image metric used. We have also discussed how this analysis can be applied to other positioning systems such as Cone Beam CT-based systems or Brainlab's ExacTrac. The estimates found by our error propagation analysis are in good agreement with the numbers found in the phantom study but significantly smaller than results from patient evaluations. We probably underestimated human influences such as the US scan head positioning by the operator and tissue deformation. Rotational errors of the tracking system can multiply these errors, depending on the relative position of tracker and probe. We were able to analyse the components of the overall error of a typical patient positioning system. We consider this to be a contribution to the optimization of the positioning accuracy for computer guidance systems.

Human Research Program Space Human Factors Engineering (SHFE) Standing Review Panel (SRP)

NASA Technical Reports Server (NTRS)

Wichansky, Anna; Badler, Norman; Butler, Keith; Cummings, Mary; DeLucia, Patricia; Endsley, Mica; Scholtz, Jean

2009-01-01

The Space Human Factors Engineering (SHFE) Standing Review Panel (SRP) evaluated 22 gaps and 39 tasks in the three risk areas assigned to the SHFE Project. The area where tasks were best designed to close the gaps and the fewest gaps were left out was the Risk of Reduced Safety and Efficiency dire to Inadequate Design of Vehicle, Environment, Tools or Equipment. The areas where there were more issues with gaps and tasks, including poor or inadequate fit of tasks to gaps and missing gaps, were Risk of Errors due to Poor Task Design and Risk of Error due to Inadequate Information. One risk, the Risk of Errors due to Inappropriate Levels of Trust in Automation, should be added. If astronauts trust automation too much in areas where it should not be trusted, but rather tempered with human judgment and decision making, they will incur errors. Conversely, if they do not trust automation when it should be trusted, as in cases where it can sense aspects of the environment such as radiation levels or distances in space, they will also incur errors. This will be a larger risk when astronauts are less able to rely on human mission control experts and are out of touch, far away, and on their own. The SRP also identified 11 new gaps and five new tasks. Although the SRP had an extremely large quantity of reading material prior to and during the meeting, we still did not feel we had an overview of the activities and tasks the astronauts would be performing in exploration missions. Without a detailed task analysis and taxonomy of activities the humans would be engaged in, we felt it was impossible to know whether the gaps and tasks were really sufficient to insure human safety, performance, and comfort in the exploration missions. The SRP had difficulty evaluating many of the gaps and tasks that were not as quantitative as those related to concrete physical danger such as excessive noise and vibration. Often the research tasks for cognitive risks that accompany poor task or information design addressed only part, but not all, of the gaps they were programmed to fill. In fact the tasks outlined will not close the gap but only scratch the surface in many cases. In other cases, the gap was written too broadly, and really should be restated in a more constrained way that can be addressed by a well-organized and complementary set of tasks. In many cases, the research results should be turned into guidelines for design. However, it was not clear whether the researchers or another group would construct and deliver these guidelines.

Diagnostic Hypothesis Generation and Human Judgment

ERIC Educational Resources Information Center

Thomas, Rick P.; Dougherty, Michael R.; Sprenger, Amber M.; Harbison, J. Isaiah

2008-01-01

Diagnostic hypothesis-generation processes are ubiquitous in human reasoning. For example, clinicians generate disease hypotheses to explain symptoms and help guide treatment, auditors generate hypotheses for identifying sources of accounting errors, and laypeople generate hypotheses to explain patterns of information (i.e., data) in the…

Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals.

PubMed

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris; Bjørn, Brian; Lilja, Beth; Mogensen, Torben

2011-03-01

Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety incidents. The objective of this study is to review RCA reports (RCAR) for characteristics of verbal communication errors between hospital staff in an organisational perspective. Two independent raters analysed 84 RCARs, conducted in six Danish hospitals between 2004 and 2006, for descriptions and characteristics of verbal communication errors such as handover errors and error during teamwork. Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13 (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between units and consults from other specialties, were particularly vulnerable processes. With the risk of bias in mind, it is concluded that more than half of the RCARs described erroneous verbal communication between staff members as root causes of or contributing factors of severe patient safety incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors.

Influence of precision of emission characteristic parameters on model prediction error of VOCs/formaldehyde from dry building material.

PubMed

Wei, Wenjuan; Xiong, Jianyin; Zhang, Yinping

2013-01-01

Mass transfer models are useful in predicting the emissions of volatile organic compounds (VOCs) and formaldehyde from building materials in indoor environments. They are also useful for human exposure evaluation and in sustainable building design. The measurement errors in the emission characteristic parameters in these mass transfer models, i.e., the initial emittable concentration (C 0), the diffusion coefficient (D), and the partition coefficient (K), can result in errors in predicting indoor VOC and formaldehyde concentrations. These errors have not yet been quantitatively well analyzed in the literature. This paper addresses this by using modelling to assess these errors for some typical building conditions. The error in C 0, as measured in environmental chambers and applied to a reference living room in Beijing, has the largest influence on the model prediction error in indoor VOC and formaldehyde concentration, while the error in K has the least effect. A correlation between the errors in D, K, and C 0 and the error in the indoor VOC and formaldehyde concentration prediction is then derived for engineering applications. In addition, the influence of temperature on the model prediction of emissions is investigated. It shows the impact of temperature fluctuations on the prediction errors in indoor VOC and formaldehyde concentrations to be less than 7% at 23±0.5°C and less than 30% at 23±2°C.

Impact of gradient timing error on the tissue sodium concentration bioscale measured using flexible twisted projection imaging

NASA Astrophysics Data System (ADS)

Lu, Aiming; Atkinson, Ian C.; Vaughn, J. Thomas; Thulborn, Keith R.

2011-12-01

The rapid biexponential transverse relaxation of the sodium MR signal from brain tissue requires efficient k-space sampling for quantitative imaging in a time that is acceptable for human subjects. The flexible twisted projection imaging (flexTPI) sequence has been shown to be suitable for quantitative sodium imaging with an ultra-short echo time to minimize signal loss. The fidelity of the k-space center location is affected by the readout gradient timing errors on the three physical axes, which is known to cause image distortion for projection-based acquisitions. This study investigated the impact of these timing errors on the voxel-wise accuracy of the tissue sodium concentration (TSC) bioscale measured with the flexTPI sequence. Our simulations show greater than 20% spatially varying quantification errors when the gradient timing errors are larger than 10 μs on all three axes. The quantification is more tolerant of gradient timing errors on the Z-axis. An existing method was used to measure the gradient timing errors with <1 μs error. The gradient timing error measurement is shown to be RF coil dependent, and timing error differences of up to ˜16 μs have been observed between different RF coils used on the same scanner. The measured timing errors can be corrected prospectively or retrospectively to obtain accurate TSC values.

An Overview of the NASA Aviation Safety Program (AVSP) Systemwide Accident Prevention (SWAP) Human Performance Modeling (HPM) Element

NASA Technical Reports Server (NTRS)

Foyle, David C.; Goodman, Allen; Hooley, Becky L.

2003-01-01

An overview is provided of the Human Performance Modeling (HPM) element within the NASA Aviation Safety Program (AvSP). Two separate model development tracks for performance modeling of real-world aviation environments are described: the first focuses on the advancement of cognitive modeling tools for system design, while the second centers on a prescriptive engineering model of activity tracking for error detection and analysis. A progressive implementation strategy for both tracks is discussed in which increasingly more complex, safety-relevant applications are undertaken to extend the state-of-the-art, as well as to reveal potential human-system vulnerabilities in the aviation domain. Of particular interest is the ability to predict the precursors to error and to assess potential mitigation strategies associated with the operational use of future flight deck technologies.

Human Factors and Ergonomics for the Dental Profession.

PubMed

Ross, Al

2016-09-01

This paper proposes that the science of Human Factors and Ergonomics (HFE) is suitable for wide application in dental education, training and practice to improve safety, quality and efficiency. Three areas of interest are highlighted. First it is proposed that individual and team Non-Technical Skills (NTS), such as communication, leadership and stress management can improve error rates and efficiency of procedures. Secondly, in a physically and technically challenging environment, staff can benefit from ergonomic principles which examine design in supporting safe work. Finally, examination of organizational human factors can help anticipate stressors and plan for flexible responses to multiple, variable demands, and fluctuating resources. Clinical relevance: HFE is an evidence-based approach to reducing error rates and procedural complications, and avoiding problems associated with stress and fatigue. Improved teamwork and organizational planning and efficiency can impact directly on patient outcomes.

[Medical errors: inevitable but preventable].

PubMed

Giard, R W

2001-10-27

Medical errors are increasingly reported in the lay press. Studies have shown dramatic error rates of 10 percent or even higher. From a methodological point of view, studying the frequency and causes of medical errors is far from simple. Clinical decisions on diagnostic or therapeutic interventions are always taken within a clinical context. Reviewing outcomes of interventions without taking into account both the intentions and the arguments for a particular action will limit the conclusions from a study on the rate and preventability of errors. The interpretation of the preventability of medical errors is fraught with difficulties and probably highly subjective. Blaming the doctor personally does not do justice to the actual situation and especially the organisational framework. Attention for and improvement of the organisational aspects of error are far more important then litigating the person. To err is and will remain human and if we want to reduce the incidence of faults we must be able to learn from our mistakes. That requires an open attitude towards medical mistakes, a continuous effort in their detection, a sound analysis and, where feasible, the institution of preventive measures.

Error image aware content restoration

NASA Astrophysics Data System (ADS)

Choi, Sungwoo; Lee, Moonsik; Jung, Byunghee

2015-12-01

As the resolution of TV significantly increased, content consumers have become increasingly sensitive to the subtlest defect in TV contents. This rising standard in quality demanded by consumers has posed a new challenge in today's context where the tape-based process has transitioned to the file-based process: the transition necessitated digitalizing old archives, a process which inevitably produces errors such as disordered pixel blocks, scattered white noise, or totally missing pixels. Unsurprisingly, detecting and fixing such errors require a substantial amount of time and human labor to meet the standard demanded by today's consumers. In this paper, we introduce a novel, automated error restoration algorithm which can be applied to different types of classic errors by utilizing adjacent images while preserving the undamaged parts of an error image as much as possible. We tested our method to error images detected from our quality check system in KBS(Korean Broadcasting System) video archive. We are also implementing the algorithm as a plugin of well-known NLE(Non-linear editing system), which is a familiar tool for quality control agent.

Unreliable numbers: error and harm induced by bad design can be reduced by better design

PubMed Central

Thimbleby, Harold; Oladimeji, Patrick; Cairns, Paul

2015-01-01

Number entry is a ubiquitous activity and is often performed in safety- and mission-critical procedures, such as healthcare, science, finance, aviation and in many other areas. We show that Monte Carlo methods can quickly and easily compare the reliability of different number entry systems. A surprising finding is that many common, widely used systems are defective, and induce unnecessary human error. We show that Monte Carlo methods enable designers to explore the implications of normal and unexpected operator behaviour, and to design systems to be more resilient to use error. We demonstrate novel designs with improved resilience, implying that the common problems identified and the errors they induce are avoidable. PMID:26354830

Medication errors in anesthesia: unacceptable or unavoidable?

PubMed

Dhawan, Ira; Tewari, Anurag; Sehgal, Sankalp; Sinha, Ashish Chandra

Medication errors are the common causes of patient morbidity and mortality. It adds financial burden to the institution as well. Though the impact varies from no harm to serious adverse effects including death, it needs attention on priority basis since medication errors' are preventable. In today's world where people are aware and medical claims are on the hike, it is of utmost priority that we curb this issue. Individual effort to decrease medication error alone might not be successful until a change in the existing protocols and system is incorporated. Often drug errors that occur cannot be reversed. The best way to 'treat' drug errors is to prevent them. Wrong medication (due to syringe swap), overdose (due to misunderstanding or preconception of the dose, pump misuse and dilution error), incorrect administration route, under dosing and omission are common causes of medication error that occur perioperatively. Drug omission and calculation mistakes occur commonly in ICU. Medication errors can occur perioperatively either during preparation, administration or record keeping. Numerous human and system errors can be blamed for occurrence of medication errors. The need of the hour is to stop the blame - game, accept mistakes and develop a safe and 'just' culture in order to prevent medication errors. The newly devised systems like VEINROM, a fluid delivery system is a novel approach in preventing drug errors due to most commonly used medications in anesthesia. Similar developments along with vigilant doctors, safe workplace culture and organizational support all together can help prevent these errors. Copyright © 2016. Published by Elsevier Editora Ltda.

Theoretical investigation of aberrations upon ametropic human eyes

NASA Astrophysics Data System (ADS)

Tan, Bo; Chen, Ying-Ling; Lewis, J. W. L.; Baker, Kevin

2003-11-01

The human eye aberrations are important for visual acuity and ophthalmic diagnostics and surgical procedures. Reported monochromatic aberration data of the normal 20/20 human eyes are scarce. There exist even fewer reports of the relation between ametropic conditions and aberrations. We theoretically investigate the monochromatic and chromatic aberrations of human eyes for refractive errors of -10 to +10 diopters. Schematic human eye models are employed using optical design software for axial, index, and refractive types of ametropia.

Altitude deviations: Breakdowns of an error-tolerant system

NASA Technical Reports Server (NTRS)

Palmer, Everett A.; Hutchins, Edwin L.; Ritter, Richard D.; Vancleemput, Inge

1993-01-01

Pilot reports of aviation incidents to the Aviation Safety Reporting System (ASRS) provide a window on the problems occurring in today's airline cockpits. The narratives of 10 pilot reports of errors made in the automation-assisted altitude-change task are used to illustrate some of the issues of pilots interacting with automatic systems. These narratives are then used to construct a description of the cockpit as an information processing system. The analysis concentrates on the error-tolerant properties of the system and on how breakdowns can occasionally occur. An error-tolerant system can detect and correct its internal processing errors. The cockpit system consists of two or three pilots supported by autoflight, flight-management, and alerting systems. These humans and machines have distributed access to clearance information and perform redundant processing of information. Errors can be detected as deviations from either expected behavior or as deviations from expected information. Breakdowns in this system can occur when the checking and cross-checking tasks that give the system its error-tolerant properties are not performed because of distractions or other task demands. Recommendations based on the analysis for improving the error tolerance of the cockpit system are given.

Dual-loop model of the human controller

NASA Technical Reports Server (NTRS)

Hess, R. A.

1978-01-01

A dual-loop model of the human controller in single-axis compensatory tracking tasks is introduced. This model possesses an inner-loop closure that involves feeding back that portion of controlled element output rate that is due to control activity. A novel feature of the model is the explicit appearance of the human's internal representation of the manipulator-controlled element dynamics in the inner loop. The sensor inputs to the human controller are assumed to be system error and control force. The former can be sensed via visual, aural, or tactile displays, whereas the latter is assumed to be sensed in kinesthetic fashion. A set of general adaptive characteristics for the model is hypothesized, including a method for selecting simplified internal models of the manipulator-controlled element dynamics. It is demonstrated that the model can produce controller describing functions that closely approximate those measured in four laboratory tracking tasks in which the controlled element dynamics vary considerably in terms of ease of control. An empirically derived expression for the normalized injected error remnant spectrum is introduced.

Toward a human-centered aircraft automation philosophy

NASA Technical Reports Server (NTRS)

Billings, Charles E.

1989-01-01

The evolution of automation in civil aircraft is examined in order to discern trends in the respective roles and functions of automation technology and the humans who operate these aircraft. The effects of advances in automation technology on crew reaction is considered and it appears that, though automation may well have decreased the frequency of certain types of human errors in flight, it may also have enabled new categories of human errors, some perhaps less obvious and therefore more serious than those it has alleviated. It is suggested that automation could be designed to keep the pilot closer to the control of the vehicle, while providing an array of information management and aiding functions designed to provide the pilot with data regarding flight replanning, degraded system operation, and the operational status and limits of the aircraft, its systems, and the physical and operational environment. The automation would serve as the pilot's assistant, providing and calculating data, watching for the unexpected, and keeping track of resources and their rate of expenditure.

Reducing diagnostic errors in medicine: what's the goal?

PubMed

Graber, Mark; Gordon, Ruthanna; Franklin, Nancy

2002-10-01

This review considers the feasibility of reducing or eliminating the three major categories of diagnostic errors in medicine: "No-fault errors" occur when the disease is silent, presents atypically, or mimics something more common. These errors will inevitably decline as medical science advances, new syndromes are identified, and diseases can be detected more accurately or at earlier stages. These errors can never be eradicated, unfortunately, because new diseases emerge, tests are never perfect, patients are sometimes noncompliant, and physicians will inevitably, at times, choose the most likely diagnosis over the correct one, illustrating the concept of necessary fallibility and the probabilistic nature of choosing a diagnosis. "System errors" play a role when diagnosis is delayed or missed because of latent imperfections in the health care system. These errors can be reduced by system improvements, but can never be eliminated because these improvements lag behind and degrade over time, and each new fix creates the opportunity for novel errors. Tradeoffs also guarantee system errors will persist, when resources are just shifted. "Cognitive errors" reflect misdiagnosis from faulty data collection or interpretation, flawed reasoning, or incomplete knowledge. The limitations of human processing and the inherent biases in using heuristics guarantee that these errors will persist. Opportunities exist, however, for improving the cognitive aspect of diagnosis by adopting system-level changes (e.g., second opinions, decision-support systems, enhanced access to specialists) and by training designed to improve cognition or cognitive awareness. Diagnostic error can be substantially reduced, but never eradicated.

Common errors of drug administration in infants: causes and avoidance.

PubMed

Anderson, B J; Ellis, J F

1999-01-01

Drug administration errors are common in infants. Although the infant population has a high exposure to drugs, there are few data concerning pharmacokinetics or pharmacodynamics, or the influence of paediatric diseases on these processes. Children remain therapeutic orphans. Formulations are often suitable only for adults; in addition, the lack of maturation of drug elimination processes, alteration of body composition and influence of size render the calculation of drug doses complex in infants. The commonest drug administration error in infants is one of dose, and the commonest hospital site for this error is the intensive care unit. Drug errors are a consequence of system error, and preventive strategies are possible through system analysis. The goal of a zero drug error rate should be aggressively sought, with systems in place that aim to eliminate the effects of inevitable human error. This involves review of the entire system from drug manufacture to drug administration. The nuclear industry, telecommunications and air traffic control services all practise error reduction policies with zero error as a clear goal, not by finding fault in the individual, but by identifying faults in the system and building into that system mechanisms for picking up faults before they occur. Such policies could be adapted to medicine using interventions both specific (the production of formulations which are for children only and clearly labelled, regular audit by pharmacists, legible prescriptions, standardised dose tables) and general (paediatric drug trials, education programmes, nonpunitive error reporting) to reduce the number of errors made in giving medication to infants.

Error reduction in EMG signal decomposition

PubMed Central

Kline, Joshua C.

2014-01-01

Decomposition of the electromyographic (EMG) signal into constituent action potentials and the identification of individual firing instances of each motor unit in the presence of ambient noise are inherently probabilistic processes, whether performed manually or with automated algorithms. Consequently, they are subject to errors. We set out to classify and reduce these errors by analyzing 1,061 motor-unit action-potential trains (MUAPTs), obtained by decomposing surface EMG (sEMG) signals recorded during human voluntary contractions. Decomposition errors were classified into two general categories: location errors representing variability in the temporal localization of each motor-unit firing instance and identification errors consisting of falsely detected or missed firing instances. To mitigate these errors, we developed an error-reduction algorithm that combines multiple decomposition estimates to determine a more probable estimate of motor-unit firing instances with fewer errors. The performance of the algorithm is governed by a trade-off between the yield of MUAPTs obtained above a given accuracy level and the time required to perform the decomposition. When applied to a set of sEMG signals synthesized from real MUAPTs, the identification error was reduced by an average of 1.78%, improving the accuracy to 97.0%, and the location error was reduced by an average of 1.66 ms. The error-reduction algorithm in this study is not limited to any specific decomposition strategy. Rather, we propose it be used for other decomposition methods, especially when analyzing precise motor-unit firing instances, as occurs when measuring synchronization. PMID:25210159

A universal role of the ventral striatum in reward-based learning: Evidence from human studies

PubMed Central

Daniel, Reka; Pollmann, Stefan

2014-01-01

Reinforcement learning enables organisms to adjust their behavior in order to maximize rewards. Electrophysiological recordings of dopaminergic midbrain neurons have shown that they code the difference between actual and predicted rewards, i.e., the reward prediction error, in many species. This error signal is conveyed to both the striatum and cortical areas and is thought to play a central role in learning to optimize behavior. However, in human daily life rewards are diverse and often only indirect feedback is available. Here we explore the range of rewards that are processed by the dopaminergic system in human participants, and examine whether it is also involved in learning in the absence of explicit rewards. While results from electrophysiological recordings in humans are sparse, evidence linking dopaminergic activity to the metabolic signal recorded from the midbrain and striatum with functional magnetic resonance imaging (fMRI) is available. Results from fMRI studies suggest that the human ventral striatum (VS) receives valuation information for a diverse set of rewarding stimuli. These range from simple primary reinforcers such as juice rewards over abstract social rewards to internally generated signals on perceived correctness, suggesting that the VS is involved in learning from trial-and-error irrespective of the specific nature of provided rewards. In addition, we summarize evidence that the VS can also be implicated when learning from observing others, and in tasks that go beyond simple stimulus-action-outcome learning, indicating that the reward system is also recruited in more complex learning tasks. PMID:24825620

Cleared for the visual approach: Human factor problems in air carrier operations

NASA Technical Reports Server (NTRS)

Monan, W. P.

1983-01-01

The study described herein, a set of 353 ASRS reports of unique aviation occurrences significantly involving visual approaches was examined to identify hazards and pitfalls embedded in the visual approach procedure and to consider operational practices that might help avoid future mishaps. Analysis of the report set identified nine aspects of the visual approach procedure that appeared to be predisposing conditions for inducing or exacerbating the effects of operational errors by flight crew members or controllers. Predisposing conditions, errors, and operational consequences of the errors are discussed. In a summary, operational policies that might mitigate the problems are examined.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Sanfilippo, Antonio P.; Riensche, Roderick M.; Haack, Jereme N.

“Gamification”, the application of gameplay to real-world problems, enables the development of human computation systems that support decision-making through the integration of social and machine intelligence. One of gamification’s major benefits includes the creation of a problem solving environment where the influence of cognitive and cultural biases on human judgment can be curtailed through collaborative and competitive reasoning. By reducing biases on human judgment, gamification allows human computation systems to exploit human creativity relatively unhindered by human error. Operationally, gamification uses simulation to harvest human behavioral data that provide valuable insights for the solution of real-world problems.

Two States Mapping Based Time Series Neural Network Model for Compensation Prediction Residual Error

NASA Astrophysics Data System (ADS)

Jung, Insung; Koo, Lockjo; Wang, Gi-Nam

2008-11-01

The objective of this paper was to design a model of human bio signal data prediction system for decreasing of prediction error using two states mapping based time series neural network BP (back-propagation) model. Normally, a lot of the industry has been applied neural network model by training them in a supervised manner with the error back-propagation algorithm for time series prediction systems. However, it still has got a residual error between real value and prediction result. Therefore, we designed two states of neural network model for compensation residual error which is possible to use in the prevention of sudden death and metabolic syndrome disease such as hypertension disease and obesity. We determined that most of the simulation cases were satisfied by the two states mapping based time series prediction model. In particular, small sample size of times series were more accurate than the standard MLP model.

Transfer Error and Correction Approach in Mobile Network

NASA Astrophysics Data System (ADS)

Xiao-kai, Wu; Yong-jin, Shi; Da-jin, Chen; Bing-he, Ma; Qi-li, Zhou

With the development of information technology and social progress, human demand for information has become increasingly diverse, wherever and whenever people want to be able to easily, quickly and flexibly via voice, data, images and video and other means to communicate. Visual information to the people direct and vivid image, image / video transmission also been widespread attention. Although the third generation mobile communication systems and the emergence and rapid development of IP networks, making video communications is becoming the main business of the wireless communications, however, the actual wireless and IP channel will lead to error generation, such as: wireless channel multi- fading channels generated error and blocking IP packet loss and so on. Due to channel bandwidth limitations, the video communication compression coding of data is often beyond the data, and compress data after the error is very sensitive to error conditions caused a serious decline in image quality.

Aged-related Neural Changes during Memory Conjunction Errors

PubMed Central

Giovanello, Kelly S.; Kensinger, Elizabeth A.; Wong, Alana T.; Schacter, Daniel L.

2013-01-01

Human behavioral studies demonstrate that healthy aging is often accompanied by increases in memory distortions or errors. Here we used event-related functional MRI to examine the neural basis of age-related memory distortions. We utilized the memory conjunction error paradigm, a laboratory procedure known to elicit high levels of memory errors. For older adults, right parahippocampal gyrus showed significantly greater activity during false than during accurate retrieval. We observed no regions in which activity was greater during false than during accurate retrieval for young adults. Young adults, however, showed significantly greater activity than old adults during accurate retrieval in right hippocampus. By contrast, older adults demonstrated greater activity than young adults during accurate retrieval in right inferior and middle prefrontal cortex. These data are consistent with the notion that age-related memory conjunction errors arise from dysfunction of hippocampal system mechanisms, rather than impairments in frontally-mediated monitoring processes. PMID:19445606

Online Deviation Detection for Medical Processes

PubMed Central

Christov, Stefan C.; Avrunin, George S.; Clarke, Lori A.

2014-01-01

Human errors are a major concern in many medical processes. To help address this problem, we are investigating an approach for automatically detecting when performers of a medical process deviate from the acceptable ways of performing that process as specified by a detailed process model. Such deviations could represent errors and, thus, detecting and reporting deviations as they occur could help catch errors before harm is done. In this paper, we identify important issues related to the feasibility of the proposed approach and empirically evaluate the approach for two medical procedures, chemotherapy and blood transfusion. For the evaluation, we use the process models to generate sample process executions that we then seed with synthetic errors. The process models describe the coordination of activities of different process performers in normal, as well as in exceptional situations. The evaluation results suggest that the proposed approach could be applied in clinical settings to help catch errors before harm is done. PMID:25954343

Errors in Aviation Decision Making: Bad Decisions or Bad Luck?

NASA Technical Reports Server (NTRS)

Orasanu, Judith; Martin, Lynne; Davison, Jeannie; Null, Cynthia H. (Technical Monitor)

1998-01-01

Despite efforts to design systems and procedures to support 'correct' and safe operations in aviation, errors in human judgment still occur and contribute to accidents. In this paper we examine how an NDM (naturalistic decision making) approach might help us to understand the role of decision processes in negative outcomes. Our strategy was to examine a collection of identified decision errors through the lens of an aviation decision process model and to search for common patterns. The second, and more difficult, task was to determine what might account for those patterns. The corpus we analyzed consisted of tactical decision errors identified by the NTSB (National Transportation Safety Board) from a set of accidents in which crew behavior contributed to the accident. A common pattern emerged: about three quarters of the errors represented plan-continuation errors, that is, a decision to continue with the original plan despite cues that suggested changing the course of action. Features in the context that might contribute to these errors were identified: (a) ambiguous dynamic conditions and (b) organizational and socially-induced goal conflicts. We hypothesize that 'errors' are mediated by underestimation of risk and failure to analyze the potential consequences of continuing with the initial plan. Stressors may further contribute to these effects. Suggestions for improving performance in these error-inducing contexts are discussed.

Human error and commercial aviation accidents: an analysis using the human factors analysis and classification system.

PubMed

Shappell, Scott; Detwiler, Cristy; Holcomb, Kali; Hackworth, Carla; Boquet, Albert; Wiegmann, Douglas A

2007-04-01

The aim of this study was to extend previous examinations of aviation accidents to include specific aircrew, environmental, supervisory, and organizational factors associated with two types of commercial aviation (air carrier and commuter/ on-demand) accidents using the Human Factors Analysis and Classification System (HFACS). HFACS is a theoretically based tool for investigating and analyzing human error associated with accidents and incidents. Previous research has shown that HFACS can be reliably used to identify human factors trends associated with military and general aviation accidents. Using data obtained from both the National Transportation Safety Board and the Federal Aviation Administration, 6 pilot-raters classified aircrew, supervisory, organizational, and environmental causal factors associated with 1020 commercial aviation accidents that occurred over a 13-year period. The majority of accident causal factors were attributed to aircrew and the environment, with decidedly fewer associated with supervisory and organizational causes. Comparisons were made between HFACS causal categories and traditional situational variables such as visual conditions, injury severity, and regional differences. These data will provide support for the continuation, modification, and/or development of interventions aimed at commercial aviation safety. HFACS provides a tool for assessing human factors associated with accidents and incidents.

Predictive models of safety based on audit findings: Part 1: Model development and reliability.

PubMed

Hsiao, Yu-Lin; Drury, Colin; Wu, Changxu; Paquet, Victor

2013-03-01

This consecutive study was aimed at the quantitative validation of safety audit tools as predictors of safety performance, as we were unable to find prior studies that tested audit validity against safety outcomes. An aviation maintenance domain was chosen for this work as both audits and safety outcomes are currently prescribed and regulated. In Part 1, we developed a Human Factors/Ergonomics classification framework based on HFACS model (Shappell and Wiegmann, 2001a,b), for the human errors detected by audits, because merely counting audit findings did not predict future safety. The framework was tested for measurement reliability using four participants, two of whom classified errors on 1238 audit reports. Kappa values leveled out after about 200 audits at between 0.5 and 0.8 for different tiers of errors categories. This showed sufficient reliability to proceed with prediction validity testing in Part 2. Copyright © 2012 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Quantification of airport community noise impact in terms of noise levels, population density, and human subjective response

NASA Technical Reports Server (NTRS)

Deloach, R.

1981-01-01

The Fraction Impact Method (FIM), developed by the National Research Council (NRC) for assessing the amount and physiological effect of noise, is described. Here, the number of people exposed to a given level of noise is multiplied by a weighting factor that depends on noise level. It is pointed out that the Aircraft-noise Levels and Annoyance MOdel (ALAMO), recently developed at NASA Langley Research Center, can perform the NRC fractional impact calculations for given modes of operation at any U.S. airport. The sensitivity of these calculations to errors in estimates of population, noise level, and human subjective response is discussed. It is found that a change in source noise causes a substantially smaller change in contour area than would be predicted simply on the basis of inverse square law considerations. Another finding is that the impact calculations are generally less sensitive to source noise errors than to systematic errors in population or subjective response.

The perils of the imperfect expectation of the perfect baby.

PubMed

Chervenak, Frank A; McCullough, Laurence B; Brent, Robert L

2010-08-01

Advances in modern medicine invite the assumption that medicine can control human biology. There is a perilous logic that leads from expectations of medicine's control over reproductive biology to the expectation of having a perfect baby. This article proposes that obstetricians should take a preventive ethics approach to the care of pregnant women with expectations for a perfect baby. We use Nathaniel Hawthorne's classic short story, "The Birthmark," to illustrate the perils of the logic of control and perfection through science and then identify possible contemporary sources of the expectation of the perfect baby. We propose that the informed consent process should be used as a preventive ethics tool throughout the course of pregnancy to educate pregnant women about the inherent errors of human reproduction, the highly variable clinical outcomes of these errors, the limited capacity of medicine to detect these errors, and the even more limited capacity to correct them. Copyright (c) 2010 Mosby, Inc. All rights reserved.

National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac surgery: error cycles precede ∼85% of patient deaths.

PubMed

Hickey, Edward J; Nosikova, Yaroslavna; Pham-Hung, Eric; Gritti, Michael; Schwartz, Steven; Caldarone, Christopher A; Redington, Andrew; Van Arsdell, Glen S

2015-02-01

We hypothesized that the National Aeronautics and Space Administration "threat and error" model (which is derived from analyzing >30,000 commercial flights, and explains >90% of crashes) is directly applicable to pediatric cardiac surgery. We implemented a unit-wide performance initiative, whereby every surgical admission constitutes a "flight" and is tracked in real time, with the aim of identifying errors. The first 500 consecutive patients (524 flights) were analyzed, with an emphasis on the relationship between error cycles and permanent harmful outcomes. Among 524 patient flights (risk adjustment for congenital heart surgery category: 1-6; median: 2) 68 (13%) involved residual hemodynamic lesions, 13 (2.5%) permanent end-organ injuries, and 7 deaths (1.3%). Preoperatively, 763 threats were identified in 379 (72%) flights. Only 51% of patient flights (267) were error free. In the remaining 257 flights, 430 errors occurred, most commonly related to proficiency (280; 65%) or judgment (69, 16%). In most flights with errors (173 of 257; 67%), an unintended clinical state resulted, ie, the error was consequential. In 60% of consequential errors (n = 110; 21% of total), subsequent cycles of additional error/unintended states occurred. Cycles, particularly those containing multiple errors, were very significantly associated with permanent harmful end-states, including residual hemodynamic lesions (P < .0001), end-organ injury (P < .0001), and death (P < .0001). Deaths were almost always preceded by cycles (6 of 7; P < .0001). Human error, if not mitigated, often leads to cycles of error and unintended patient states, which are dangerous and precede the majority of harmful outcomes. Efforts to manage threats and error cycles (through crew resource management techniques) are likely to yield large increases in patient safety. Copyright © 2015. Published by Elsevier Inc.

Paediatric in-patient prescribing errors in Malaysia: a cross-sectional multicentre study.

PubMed

Khoo, Teik Beng; Tan, Jing Wen; Ng, Hoong Phak; Choo, Chong Ming; Bt Abdul Shukor, Intan Nor Chahaya; Teh, Siao Hean

2017-06-01

Background There is a lack of large comprehensive studies in developing countries on paediatric in-patient prescribing errors in different settings. Objectives To determine the characteristics of in-patient prescribing errors among paediatric patients. Setting General paediatric wards, neonatal intensive care units and paediatric intensive care units in government hospitals in Malaysia. Methods This is a cross-sectional multicentre study involving 17 participating hospitals. Drug charts were reviewed in each ward to identify the prescribing errors. All prescribing errors identified were further assessed for their potential clinical consequences, likely causes and contributing factors. Main outcome measures Incidence, types, potential clinical consequences, causes and contributing factors of the prescribing errors. Results The overall prescribing error rate was 9.2% out of 17,889 prescribed medications. There was no significant difference in the prescribing error rates between different types of hospitals or wards. The use of electronic prescribing had a higher prescribing error rate than manual prescribing (16.9 vs 8.2%, p < 0.05). Twenty eight (1.7%) prescribing errors were deemed to have serious potential clinical consequences and 2 (0.1%) were judged to be potentially fatal. Most of the errors were attributed to human factors, i.e. performance or knowledge deficit. The most common contributing factors were due to lack of supervision or of knowledge. Conclusions Although electronic prescribing may potentially improve safety, it may conversely cause prescribing errors due to suboptimal interfaces and cumbersome work processes. Junior doctors need specific training in paediatric prescribing and close supervision to reduce prescribing errors in paediatric in-patients.

Incident reporting: Its role in aviation safety and the acquisition of human error data

NASA Technical Reports Server (NTRS)

Reynard, W. D.

1983-01-01

The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

Accuracy of Noninvasive Estimation Techniques for the State of the Cochlear Amplifier

NASA Astrophysics Data System (ADS)

Dalhoff, Ernst; Gummer, Anthony W.

2011-11-01

Estimation of the function of the cochlea in human is possible only by deduction from indirect measurements, which may be subjective or objective. Therefore, for basic research as well as diagnostic purposes, it is important to develop methods to deduce and analyse error sources of cochlear-state estimation techniques. Here, we present a model of technical and physiologic error sources contributing to the estimation accuracy of hearing threshold and the state of the cochlear amplifier and deduce from measurements of human that the estimated standard deviation can be considerably below 6 dB. Experimental evidence is drawn from two partly independent objective estimation techniques for the auditory signal chain based on measurements of otoacoustic emissions.

Physical security and cyber security issues and human error prevention for 3D printed objects: detecting the use of an incorrect printing material

NASA Astrophysics Data System (ADS)

Straub, Jeremy

2017-06-01

A wide variety of characteristics of 3D printed objects have been linked to impaired structural integrity and use-efficacy. The printing material can also have a significant impact on the quality, utility and safety characteristics of a 3D printed object. Material issues can be created by vendor issues, physical security issues and human error. This paper presents and evaluates a system that can be used to detect incorrect material use in a 3D printer, using visible light imaging. Specifically, it assesses the ability to ascertain the difference between materials of different color and different types of material with similar coloration.

Using Broken Windows Theory as the Backdrop for a Proactive Approach to Threat Identification in Health Care.

PubMed

Boquet, Albert J; Cohen, Tara N; Cabrera, Jennifer S; Litzinger, Tracy L; Captain, Kevin A; Fabian, Michael A; Miles, Steven G; Shappell, Scott A

2016-09-09

Historically, health care has relied on error management techniques to measure and reduce the occurrence of adverse events. This study proposes an alternative approach for identifying and analyzing hazardous events. Whereas previous research has concentrated on investigating individual flow disruptions, we maintain the industry should focus on threat windows, or the accumulation of these disruptions. This methodology, driven by the broken windows theory, allows us to identify process inefficiencies before they manifest and open the door for the occurrence of errors and adverse events. Medical human factors researchers observed disruptions during 34 trauma cases at a Level II trauma center. Data were collected during resuscitation and imaging and were classified using a human factors taxonomy: Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis (RIPCHORD-TWA). Of the 576 total disruptions observed, communication issues were the most prevalent (28%), followed by interruptions and coordination issues (24% each). Issues related to layout (16%), usability (5%), and equipment (2%) comprised the remainder of the observations. Disruptions involving communication issues were more prevalent during resuscitation, whereas coordination problems were observed more frequently during imaging. Rather than solely investigating errors and adverse events, we propose conceptualizing the accumulation of disruptions in terms of threat windows as a means to analyze potential threats to the integrity of the trauma care system. This approach allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

Human Factors in Aircraft Maintenance

DTIC Science & Technology

2001-03-01

795 - 3-798. Reason, J . (1990). Human Error. Cambridge: Cambridge University Press. Schmidt, J ., Schmorrow, D . and Figlock, R. (2000). Human factors...and so on. When each step is described in sufficient detail, the task description is complete and task analysis can begin (e.g. Drury, Paramore , Van... Paramore , B., Van Cott, H.P., Grey, S.M. and Corlett, E.M.(1987). Task analysis. In G. Salvendy (Ed) Handbook of Human Factors, Chapter 3.4. New

Crew system dynamics - Combining humans and automation

NASA Technical Reports Server (NTRS)

Connors, Mary

1989-01-01

Some of the human factor issues involved in effectively combining human and automated systems are examined with particular reference to spaceflights. The concepts of the crew system and crew systems dynamics are defined, and the present status of crew systems is summarized. The possibilities and potential problems aasociated with the use of automated systems are discussed, as are unique capabilities and possible errors introduced by human participants. It is emphasized that the true integration of human and automated systems must allow for the characteristics of both.

Ketamine Effects on Memory Reconsolidation Favor a Learning Model of Delusions

PubMed Central

Gardner, Jennifer M.; Piggot, Jennifer S.; Turner, Danielle C.; Everitt, Jessica C.; Arana, Fernando Sergio; Morgan, Hannah L.; Milton, Amy L.; Lee, Jonathan L.; Aitken, Michael R. F.; Dickinson, Anthony; Everitt, Barry J.; Absalom, Anthony R.; Adapa, Ram; Subramanian, Naresh; Taylor, Jane R.; Krystal, John H.; Fletcher, Paul C.

2013-01-01

Delusions are the persistent and often bizarre beliefs that characterise psychosis. Previous studies have suggested that their emergence may be explained by disturbances in prediction error-dependent learning. Here we set up complementary studies in order to examine whether such a disturbance also modulates memory reconsolidation and hence explains their remarkable persistence. First, we quantified individual brain responses to prediction error in a causal learning task in 18 human subjects (8 female). Next, a placebo-controlled within-subjects study of the impact of ketamine was set up on the same individuals. We determined the influence of this NMDA receptor antagonist (previously shown to induce aberrant prediction error signal and lead to transient alterations in perception and belief) on the evolution of a fear memory over a 72 hour period: they initially underwent Pavlovian fear conditioning; 24 hours later, during ketamine or placebo administration, the conditioned stimulus (CS) was presented once, without reinforcement; memory strength was then tested again 24 hours later. Re-presentation of the CS under ketamine led to a stronger subsequent memory than under placebo. Moreover, the degree of strengthening correlated with individual vulnerability to ketamine's psychotogenic effects and with prediction error brain signal. This finding was partially replicated in an independent sample with an appetitive learning procedure (in 8 human subjects, 4 female). These results suggest a link between altered prediction error, memory strength and psychosis. They point to a core disruption that may explain not only the emergence of delusional beliefs but also their persistence. PMID:23776445

Radiology's Achilles' heel: error and variation in the interpretation of the Röntgen image.

PubMed

Robinson, P J

1997-11-01

The performance of the human eye and brain has failed to keep pace with the enormous technical progress in the first full century of radiology. Errors and variations in interpretation now represent the weakest aspect of clinical imaging. Those interpretations which differ from the consensus view of a panel of "experts" may be regarded as errors; where experts fail to achieve consensus, differing reports are regarded as "observer variation". Errors arise from poor technique, failures of perception, lack of knowledge and misjudgments. Observer variation is substantial and should be taken into account when different diagnostic methods are compared; in many cases the difference between observers outweighs the difference between techniques. Strategies for reducing error include attention to viewing conditions, training of the observers, availability of previous films and relevant clinical data, dual or multiple reporting, standardization of terminology and report format, and assistance from computers. Digital acquisition and display will probably not affect observer variation but the performance of radiologists, as measured by receiver operating characteristic (ROC) analysis, may be improved by computer-directed search for specific image features. Other current developments show that where image features can be comprehensively described, computer analysis can replace the perception function of the observer, whilst the function of interpretation can in some cases be performed better by artificial neural networks. However, computer-assisted diagnosis is still in its infancy and complete replacement of the human observer is as yet a remote possibility.

[Innovative training for enhancing patient safety. Safety culture and integrated concepts].

PubMed

Rall, M; Schaedle, B; Zieger, J; Naef, W; Weinlich, M

2002-11-01

Patient safety is determined by the performance safety of the medical team. Errors in medicine are amongst the leading causes of death of hospitalized patients. These numbers call for action. Backgrounds, methods and new forms of training are introduced in this article. Concepts from safety research are transformed to the field of emergency medical treatment. Strategies from realistic patient simulator training sessions and innovative training concepts are discussed. The reasons for the high numbers of errors in medicine are not due to a lack of medical knowledge, but due to human factors and organisational circumstances. A first step towards an improved patient safety is to accept this. We always need to be prepared that errors will occur. A next step would be to separate "error" from guilt (culture of blame) allowing for a real analysis of accidents and establishment of meaningful incident reporting systems. Concepts with a good success record from aviation like "crew resource management" (CRM) training have been adapted my medicine and are ready to use. These concepts require theoretical education as well as practical training. Innovative team training sessions using realistic patient simulator systems with video taping (for self reflexion) and interactive debriefing following the sessions are very promising. As the need to reduce error rates in medicine is very high and the reasons, methods and training concepts are known, we are urged to implement these new training concepts widely and consequently. To err is human - not to counteract it is not.

Intrinsic interactive reinforcement learning - Using error-related potentials for real world human-robot interaction.

PubMed

Kim, Su Kyoung; Kirchner, Elsa Andrea; Stefes, Arne; Kirchner, Frank

2017-12-14

Reinforcement learning (RL) enables robots to learn its optimal behavioral strategy in dynamic environments based on feedback. Explicit human feedback during robot RL is advantageous, since an explicit reward function can be easily adapted. However, it is very demanding and tiresome for a human to continuously and explicitly generate feedback. Therefore, the development of implicit approaches is of high relevance. In this paper, we used an error-related potential (ErrP), an event-related activity in the human electroencephalogram (EEG), as an intrinsically generated implicit feedback (rewards) for RL. Initially we validated our approach with seven subjects in a simulated robot learning scenario. ErrPs were detected online in single trial with a balanced accuracy (bACC) of 91%, which was sufficient to learn to recognize gestures and the correct mapping between human gestures and robot actions in parallel. Finally, we validated our approach in a real robot scenario, in which seven subjects freely chose gestures and the real robot correctly learned the mapping between gestures and actions (ErrP detection (90% bACC)). In this paper, we demonstrated that intrinsically generated EEG-based human feedback in RL can successfully be used to implicitly improve gesture-based robot control during human-robot interaction. We call our approach intrinsic interactive RL.

Impairment of immunity to Candida and Mycobacterium in humans with bi-allelic RORC mutations*

PubMed Central

Halwani, Rabih; Ma, Cindy S.; Wong, Natalie; Soudais, Claire; Henderson, Lauren A.; Marzouqa, Hiyam; Shamma, Jamal; Gonzalez, Marcela; Martinez-Barricarte, Rubén; Okada, Chizuru; Avery, Danielle T.; Latorre, Daniela; Deswarte, Caroline; Jabot-Hanin, Fabienne; Torrado, Egidio; Fountain, Jeffrey; Belkadi, Aziz; Itan, Yuval; Boisson, Bertrand; Migaud, Mélanie; Arlehamn, Cecilia S. Lindestam; Sette, Alessandro; Breton, Sylvain; McCluskey, James; Rossjohn, Jamie; de Villartay, Jean-Pierre; Moshous, Despina; Hambleton, Sophie; Latour, Sylvain; Arkwright, Peter D.; Picard, Capucine; Lantz, Olivier; Engelhard, Dan; Kobayashi, Masao; Abel, Laurent; Casanova, Jean-Laurent

2015-01-01

Human inborn errors of immunity mediated by the cytokines interleukin (IL)-17A/F underlie mucocutaneous candidiasis, whereas inborn errors of interferon (IFN)-γ immunity underlie mycobacterial disease. We report the discovery of bi-allelic RORC loss-of-function mutations in seven individuals from three kindreds of different ethnic origins with both candidiasis and mycobacteriosis. The lack of functional RORγ and RORγT isoforms resulted in the absence of IL-17A/F-producing T cells in these individuals, probably accounting for their chronic candidiasis. Unexpectedly, leukocytes from RORγ- and RORγT-deficient individuals also displayed an impaired IFN-γ response to Mycobacterium. This principally reflected profoundly defective IFN-γ production by circulating γδ T cells and CD4+CCR6+ CXCR3+ αβ T cells. In humans, both mucocutaneous immunity to Candida and systemic immunity to Mycobacterium require RORγ, or RORγT, or both. PMID:26160376

Property and the human body: a proposal for posthumous conception.

PubMed

Ball, Eli Byron Stuart

2008-02-01

There is no greater error in law and bioethics than the continuing opposition to applying the concept of property to posthumous conception cases and the human body generally. The aim of this article is to challenge this error and the assumptions underpinning it. The language of property, conceived of as a "web of interests", can be used to capture and identify the social, moral and ethical concerns that arise in cases concerning the human body, a position that finds support from a correct reading of the early High Court of Australia's decision in Doodeward v Spence (1908) 6 CLR 406. However, a key issue on which the language of property is silent is how to quantify the various competing interests in the posthumous conception case: the concept is useful only insofar as it provides the device for capturing the entirety of the posthumous conception problem.

Human performance in the modern cockpit

NASA Technical Reports Server (NTRS)

Dismukes, R. K.; Cohen, M. M.

1992-01-01

This panel was organized by the Aerospace Human Factors Committee to illustrate behavioral research on the perceptual, cognitive, and group processes that determine crew effectiveness in modern cockpits. Crew reactions to the introduction of highly automated systems in the cockpit will be reported on. Automation can improve operational capabilities and efficiency and can reduce some types of human error, but may also introduce entirely new opportunities for error. The problem solving and decision making strategies used by crews led by captains with various personality profiles will be discussed. Also presented will be computational approaches to modeling the cognitive demands of cockpit operations and the cognitive capabilities and limitations of crew members. Factors contributing to aircrew deviations from standard operating procedures and misuse of checklist, often leading to violations, incidents, or accidents will be examined. The mechanisms of visual perception pilots use in aircraft control and the implications of these mechanisms for effective design of visual displays will be discussed.

Human Factors Effecting Forensic Decision Making: Workplace Stress and Well-being.

PubMed

Jeanguenat, Amy M; Dror, Itiel E

2018-01-01

Over the past decade, there has been a growing openness about the importance of human factors in forensic work. However, most of it focused on cognitive bias, and neglected issues of workplace wellness and stress. Forensic scientists work in a dynamic environment that includes common workplace pressures such as workload volume, tight deadlines, lack of advancement, number of working hours, low salary, technology distractions, and fluctuating priorities. However, in addition, forensic scientists also encounter a number of industry-specific pressures, such as technique criticism, repeated exposure to crime scenes or horrific case details, access to funding, working in an adversarial legal system, and zero tolerance for "errors". Thus, stress is an important human factor to mitigate for overall error management, productivity and decision quality (not to mention the well-being of the examiners themselves). Techniques such as mindfulness can become powerful tools to enhance work and decision quality. © 2017 American Academy of Forensic Sciences.

Using model order tests to determine sensory inputs in a motion study

NASA Technical Reports Server (NTRS)

Repperger, D. W.; Junker, A. M.

1977-01-01

In the study of motion effects on tracking performance, a problem of interest is the determination of what sensory inputs a human uses in controlling his tracking task. In the approach presented here a simple canonical model (FID or a proportional, integral, derivative structure) is used to model the human's input-output time series. A study of significant changes in reduction of the output error loss functional is conducted as different permutations of parameters are considered. Since this canonical model includes parameters which are related to inputs to the human (such as the error signal, its derivatives and integration), the study of model order is equivalent to the study of which sensory inputs are being used by the tracker. The parameters are obtained which have the greatest effect on reducing the loss function significantly. In this manner the identification procedure converts the problem of testing for model order into the problem of determining sensory inputs.

"... As we forgive those who trespass against us...": theological reflections on sin and guilt in the hospital environment.

PubMed

Schmidt, Kurt W

2005-08-01

In general parlance the term sin has lost its existential meaning. Originally a Jewish-Christian term within a purely religious context, referring to a wrongdoing with regard to God, sin has slowly become reduced to guilt in the course of the secularization process. Guilt refers to a wrongdoing, especially with regard to fellow human beings. It also refers to errors of judgement with what can be tragic consequences. These errors can occur whenever human beings are called upon to act, including the hospital environment. A Christian hospital has to address the issue of how to deal not only with guilt-ridden misdemeanors, but also with wrongdoing unto God, which overshadows every instance of guilt-ridden human behavior. Here, as in every parish, the Church Service is the place to acknowledge sin, confess sin, and forgive sin, beyond the boundaries of the parish itself.

Isolation and characterization of high affinity aptamers against DNA polymerase iota.

PubMed

Lakhin, Andrei V; Kazakov, Andrei A; Makarova, Alena V; Pavlov, Yuri I; Efremova, Anna S; Shram, Stanislav I; Tarantul, Viacheslav Z; Gening, Leonid V

2012-02-01

Human DNA-polymerase iota (Pol ι) is an extremely error-prone enzyme and the fidelity depends on the sequence context of the template. Using the in vitro systematic evolution of ligands by exponential enrichment (SELEX) procedure, we obtained an oligoribonucleotide with a high affinity to human Pol ι, named aptamer IKL5. We determined its dissociation constant with homogenous preparation of Pol ι and predicted its putative secondary structure. The aptamer IKL5 specifically inhibits DNA-polymerase activity of the purified enzyme Pol ι, but did not inhibit the DNA-polymerase activities of human DNA polymerases beta and kappa. IKL5 suppressed the error-prone DNA-polymerase activity of Pol ι also in cellular extracts of the tumor cell line SKOV-3. The aptamer IKL5 is useful for studies of the biological role of Pol ι and as a potential drug to suppress the increase of the activity of this enzyme in malignant cells.

A biologically inspired neural model for visual and proprioceptive integration including sensory training.

PubMed

Saidi, Maryam; Towhidkhah, Farzad; Gharibzadeh, Shahriar; Lari, Abdolaziz Azizi

2013-12-01

Humans perceive the surrounding world by integration of information through different sensory modalities. Earlier models of multisensory integration rely mainly on traditional Bayesian and causal Bayesian inferences for single causal (source) and two causal (for two senses such as visual and auditory systems), respectively. In this paper a new recurrent neural model is presented for integration of visual and proprioceptive information. This model is based on population coding which is able to mimic multisensory integration of neural centers in the human brain. The simulation results agree with those achieved by casual Bayesian inference. The model can also simulate the sensory training process of visual and proprioceptive information in human. Training process in multisensory integration is a point with less attention in the literature before. The effect of proprioceptive training on multisensory perception was investigated through a set of experiments in our previous study. The current study, evaluates the effect of both modalities, i.e., visual and proprioceptive training and compares them with each other through a set of new experiments. In these experiments, the subject was asked to move his/her hand in a circle and estimate its position. The experiments were performed on eight subjects with proprioception training and eight subjects with visual training. Results of the experiments show three important points: (1) visual learning rate is significantly more than that of proprioception; (2) means of visual and proprioceptive errors are decreased by training but statistical analysis shows that this decrement is significant for proprioceptive error and non-significant for visual error, and (3) visual errors in training phase even in the beginning of it, is much less than errors of the main test stage because in the main test, the subject has to focus on two senses. The results of the experiments in this paper is in agreement with the results of the neural model simulation.

Comprehensive replication of the relationship between myopia-related genes and refractive errors in a large Japanese cohort.

PubMed

Yoshikawa, Munemitsu; Yamashiro, Kenji; Miyake, Masahiro; Oishi, Maho; Akagi-Kurashige, Yumiko; Kumagai, Kyoko; Nakata, Isao; Nakanishi, Hideo; Oishi, Akio; Gotoh, Norimoto; Yamada, Ryo; Matsuda, Fumihiko; Yoshimura, Nagahisa

2014-10-21

We investigated the association between refractive error in a Japanese population and myopia-related genes identified in two recent large-scale genome-wide association studies. Single-nucleotide polymorphisms (SNPs) in 51 genes that were reported by the Consortium for Refractive Error and Myopia and/or the 23andMe database were genotyped in 3712 healthy Japanese volunteers from the Nagahama Study using HumanHap610K Quad, HumanOmni2.5M, and/or HumanExome Arrays. To evaluate the association between refractive error and recently identified myopia-related genes, we used three approaches to perform quantitative trait locus analyses of mean refractive error in both eyes of the participants: per-SNP, gene-based top-SNP, and gene-based all-SNP analyses. Association plots of successfully replicated genes also were investigated. In our per-SNP analysis, eight myopia gene associations were replicated successfully: GJD2, RASGRF1, BICC1, KCNQ5, CD55, CYP26A1, LRRC4C, and B4GALNT2.Seven additional gene associations were replicated in our gene-based analyses: GRIA4, BMP2, QKI, BMP4, SFRP1, SH3GL2, and EHBP1L1. The signal strength of the reported SNPs and their tagging SNPs increased after considering different linkage disequilibrium patterns across ethnicities. Although two previous studies suggested strong associations between PRSS56, LAMA2, TOX, and RDH5 and myopia, we could not replicate these results. Our results confirmed the significance of the myopia-related genes reported previously and suggested that gene-based replication analyses are more effective than per-SNP analyses. Our comparison with two previous studies suggested that BMP3 SNPs cause myopia primarily in Caucasian populations, while they may exhibit protective effects in Asian populations. Copyright 2014 The Association for Research in Vision and Ophthalmology, Inc.

INFORMATION OR NOISE. AN INVESTIGATION OF RESPONSE ERRORS.

DTIC Science & Technology

BEHAVIOR, SOCIAL PSYCHOLOGY), (* SOCIAL SCIENCES, SCIENTIFIC RESEARCH), PERFORMANCE(HUMAN), REACTION(PSYCHOLOGY), TEST CONSTRUCTION(PSYCHOLOGY), ATTITUDES(PSYCHOLOGY), MOTIVATION, PSYCHOLOGICAL TESTS, PUBLIC OPINION

Catching errors with patient-specific pretreatment machine log file analysis.

PubMed

Rangaraj, Dharanipathy; Zhu, Mingyao; Yang, Deshan; Palaniswaamy, Geethpriya; Yaddanapudi, Sridhar; Wooten, Omar H; Brame, Scott; Mutic, Sasa

2013-01-01

A robust, efficient, and reliable quality assurance (QA) process is highly desired for modern external beam radiation therapy treatments. Here, we report the results of a semiautomatic, pretreatment, patient-specific QA process based on dynamic machine log file analysis clinically implemented for intensity modulated radiation therapy (IMRT) treatments delivered by high energy linear accelerators (Varian 2100/2300 EX, Trilogy, iX-D, Varian Medical Systems Inc, Palo Alto, CA). The multileaf collimator machine (MLC) log files are called Dynalog by Varian. Using an in-house developed computer program called "Dynalog QA," we automatically compare the beam delivery parameters in the log files that are generated during pretreatment point dose verification measurements, with the treatment plan to determine any discrepancies in IMRT deliveries. Fluence maps are constructed and compared between the delivered and planned beams. Since clinical introduction in June 2009, 912 machine log file analyses QA were performed by the end of 2010. Among these, 14 errors causing dosimetric deviation were detected and required further investigation and intervention. These errors were the result of human operating mistakes, flawed treatment planning, and data modification during plan file transfer. Minor errors were also reported in 174 other log file analyses, some of which stemmed from false positives and unreliable results; the origins of these are discussed herein. It has been demonstrated that the machine log file analysis is a robust, efficient, and reliable QA process capable of detecting errors originating from human mistakes, flawed planning, and data transfer problems. The possibility of detecting these errors is low using point and planar dosimetric measurements. Copyright © 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

MO-FG-303-04: A Smartphone Application for Automated Mechanical Quality Assurance of Medical Accelerators

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kim, H; Lee, H; Choi, K

Purpose: The mechanical quality assurance (QA) of medical accelerators consists of a time consuming series of procedures. Since most of the procedures are done manually – e.g., checking gantry rotation angle with the naked eye using a level attached to the gantry –, it is considered to be a process with high potential for human errors. To remove the possibilities of human errors and reduce the procedure duration, we developed a smartphone application for automated mechanical QA. Methods: The preparation for the automated process was done by attaching a smartphone to the gantry facing upward. For the assessments of gantrymore » and collimator angle indications, motion sensors (gyroscope, accelerator, and magnetic field sensor) embedded in the smartphone were used. For the assessments of jaw position indicator, cross-hair centering, and optical distance indicator (ODI), an optical-image processing module using a picture taken by the high-resolution camera embedded in the smartphone was implemented. The application was developed with the Android software development kit (SDK) and OpenCV library. Results: The system accuracies in terms of angle detection error and length detection error were < 0.1° and < 1 mm, respectively. The mean absolute error for gantry and collimator rotation angles were 0.03° and 0.041°, respectively. The mean absolute error for the measured light field size was 0.067 cm. Conclusion: The automated system we developed can be used for the mechanical QA of medical accelerators with proven accuracy. For more convenient use of this application, the wireless communication module is under development. This system has a strong potential for the automation of the other QA procedures such as light/radiation field coincidence and couch translation/rotations.« less

Influence of Precision of Emission Characteristic Parameters on Model Prediction Error of VOCs/Formaldehyde from Dry Building Material

PubMed Central

Wei, Wenjuan; Xiong, Jianyin; Zhang, Yinping

2013-01-01

Mass transfer models are useful in predicting the emissions of volatile organic compounds (VOCs) and formaldehyde from building materials in indoor environments. They are also useful for human exposure evaluation and in sustainable building design. The measurement errors in the emission characteristic parameters in these mass transfer models, i.e., the initial emittable concentration (C 0), the diffusion coefficient (D), and the partition coefficient (K), can result in errors in predicting indoor VOC and formaldehyde concentrations. These errors have not yet been quantitatively well analyzed in the literature. This paper addresses this by using modelling to assess these errors for some typical building conditions. The error in C 0, as measured in environmental chambers and applied to a reference living room in Beijing, has the largest influence on the model prediction error in indoor VOC and formaldehyde concentration, while the error in K has the least effect. A correlation between the errors in D, K, and C 0 and the error in the indoor VOC and formaldehyde concentration prediction is then derived for engineering applications. In addition, the influence of temperature on the model prediction of emissions is investigated. It shows the impact of temperature fluctuations on the prediction errors in indoor VOC and formaldehyde concentrations to be less than 7% at 23±0.5°C and less than 30% at 23±2°C. PMID:24312497

Performance Data Errors in Air Carrier Operations: Causes and Countermeasures

NASA Technical Reports Server (NTRS)

Berman, Benjamin A.; Dismukes, R Key; Jobe, Kimberly K.

2012-01-01

Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.

Microsatellite Interruptions Stabilize Primate Genomes and Exist as Population-Specific Single Nucleotide Polymorphisms within Individual Human Genomes

PubMed Central

Ananda, Guruprasad; Hile, Suzanne E.; Breski, Amanda; Wang, Yanli; Kelkar, Yogeshwar; Makova, Kateryna D.; Eckert, Kristin A.

2014-01-01

Interruptions of microsatellite sequences impact genome evolution and can alter disease manifestation. However, human polymorphism levels at interrupted microsatellites (iMSs) are not known at a genome-wide scale, and the pathways for gaining interruptions are poorly understood. Using the 1000 Genomes Phase-1 variant call set, we interrogated mono-, di-, tri-, and tetranucleotide repeats up to 10 units in length. We detected ∼26,000–40,000 iMSs within each of four human population groups (African, European, East Asian, and American). We identified population-specific iMSs within exonic regions, and discovered that known disease-associated iMSs contain alleles present at differing frequencies among the populations. By analyzing longer microsatellites in primate genomes, we demonstrate that single interruptions result in a genome-wide average two- to six-fold reduction in microsatellite mutability, as compared with perfect microsatellites. Centrally located interruptions lowered mutability dramatically, by two to three orders of magnitude. Using a biochemical approach, we tested directly whether the mutability of a specific iMS is lower because of decreased DNA polymerase strand slippage errors. Modeling the adenomatous polyposis coli tumor suppressor gene sequence, we observed that a single base substitution interruption reduced strand slippage error rates five- to 50-fold, relative to a perfect repeat, during synthesis by DNA polymerases α, β, or η. Computationally, we demonstrate that iMSs arise primarily by base substitution mutations within individual human genomes. Our biochemical survey of human DNA polymerase α, β, δ, κ, and η error rates within certain microsatellites suggests that interruptions are created most frequently by low fidelity polymerases. Our combined computational and biochemical results demonstrate that iMSs are abundant in human genomes and are sources of population-specific genetic variation that may affect genome stability. The genome-wide identification of iMSs in human populations presented here has important implications for current models describing the impact of microsatellite polymorphisms on gene expression. PMID:25033203

Sharing control with haptics: seamless driver support from manual to automatic control.

PubMed

Mulder, Mark; Abbink, David A; Boer, Erwin R

2012-10-01

Haptic shared control was investigated as a human-machine interface that can intuitively share control between drivers and an automatic controller for curve negotiation. As long as automation systems are not fully reliable, a role remains for the driver to be vigilant to the system and the environment to catch any automation errors. The conventional binary switches between supervisory and manual control has many known issues, and haptic shared control is a promising alternative. A total of 42 respondents of varying age and driving experience participated in a driving experiment in a fixed-base simulator, in which curve negotiation behavior during shared control was compared to during manual control, as well as to three haptic tunings of an automatic controller without driver intervention. Under the experimental conditions studied, the main beneficial effect of haptic shared control compared to manual control was that less control activity (16% in steering wheel reversal rate, 15% in standard deviation of steering wheel angle) was needed for realizing an improved safety performance (e.g., 11% in peak lateral error). Full automation removed the need for any human control activity and improved safety performance (e.g., 35% in peak lateral error) but put the human in a supervisory position. Haptic shared control kept the driver in the loop, with enhanced performance at reduced control activity, mitigating the known issues that plague full automation. Haptic support for vehicular control ultimately seeks to intuitively combine human intelligence and creativity with the benefits of automation systems.

A classification on human factor accident/incident of China civil aviation in recent twelve years.

PubMed

Luo, Xiao-li

2004-10-01

To study human factor accident/incident occurred during 1990-2001 using new classification standard. The human factor accident/incident classification standard is developed on the basis of Reason's Model, combining with CAAC's traditional classifying method, and applied to the classified statistical analysis for 361 flying incidents and 35 flight accidents of China civil aviation, which is induced by human factors and occurred from 1990 to 2001. 1) the incident percentage of taxi and cruise is higher than that of takeoff, climb and descent. 2) The dominating type of flight incidents is diverging of runway, overrunning, near-miss, tail/wingtip/engine strike and ground obstacle impacting. 3) The top three accidents are out of control caused by crew, mountain collision and over runway. 4) Crew's basic operating skill is lower than what we imagined, the mostly representation is poor correcting ability when flight error happened. 5) Crew errors can be represented by incorrect control, regulation and procedure violation, disorientation and diverging percentage of correct flight level. The poor CRM skill is the dominant factor impacting China civil aviation safety, this result has a coincidence with previous study, but there is much difference and distinct characteristic in top incident phase, the type of crew error and behavior performance compared with that of advanced countries. We should strengthen CRM training for all of pilots aiming at the Chinese pilot behavior characteristic in order to improve the safety level of China civil aviation.

Social Interaction with an “Unidentified Moving Object” Elicits A-Not-B Error in Domestic Dogs

PubMed Central

Newberry, Ruth C.; Miklósi, Ádám

2016-01-01

Mechanical “unidentified moving objects” (UMO’s) are useful for controlled investigations into features of social interaction that generate cooperativeness and positive social affiliation in domestic dogs (Canis familiaris). We hypothesized that, if a UMO interacted socially with a dog, the UMO would become associated with certain social cues and would subsequently affect dog behaviour. We assigned dogs to a Human, Social UMO or Non-Social UMO partner. In the Human and Social UMO conditions, the partner interacted with the dog cooperatively whereas the Non-Social UMO partner was unresponsive to the dog’s actions. We then tested dogs with their partner in a Piagetian A-not-B error paradigm, predicting that the Human and Social UMO partners would be more likely to elicit A-not-B errors in dogs than the Non-Social UMO partner. Five trials were conducted in which the dog watched its partner hide a ball behind one of two screens (A or B). As predicted, dogs in the Human and Social UMO conditions were more likely to search for the ball behind the A screen during B trials than dogs in the Non-Social UMO condition. These results reveal that the unfamiliar partner’s social responsiveness leads rapidly to accepting information communicated by the partner. This study has generated a better understanding of crucial features of agents that promote dog social behaviour, which will facilitate the programming of robots for various cooperative tasks. PMID:27073867

Social Interaction with an "Unidentified Moving Object" Elicits A-Not-B Error in Domestic Dogs.

PubMed

Gergely, Anna; Compton, Anna B; Newberry, Ruth C; Miklósi, Ádám

2016-01-01

Mechanical "unidentified moving objects" (UMO's) are useful for controlled investigations into features of social interaction that generate cooperativeness and positive social affiliation in domestic dogs (Canis familiaris). We hypothesized that, if a UMO interacted socially with a dog, the UMO would become associated with certain social cues and would subsequently affect dog behaviour. We assigned dogs to a Human, Social UMO or Non-Social UMO partner. In the Human and Social UMO conditions, the partner interacted with the dog cooperatively whereas the Non-Social UMO partner was unresponsive to the dog's actions. We then tested dogs with their partner in a Piagetian A-not-B error paradigm, predicting that the Human and Social UMO partners would be more likely to elicit A-not-B errors in dogs than the Non-Social UMO partner. Five trials were conducted in which the dog watched its partner hide a ball behind one of two screens (A or B). As predicted, dogs in the Human and Social UMO conditions were more likely to search for the ball behind the A screen during B trials than dogs in the Non-Social UMO condition. These results reveal that the unfamiliar partner's social responsiveness leads rapidly to accepting information communicated by the partner. This study has generated a better understanding of crucial features of agents that promote dog social behaviour, which will facilitate the programming of robots for various cooperative tasks.

Intermittently-visual Tracking Experiments Reveal the Roles of Error-correction and Predictive Mechanisms in the Human Visual-motor Control System

NASA Astrophysics Data System (ADS)

Hayashi, Yoshikatsu; Tamura, Yurie; Sase, Kazuya; Sugawara, Ken; Sawada, Yasuji

Prediction mechanism is necessary for human visual motion to compensate a delay of sensory-motor system. In a previous study, “proactive control” was discussed as one example of predictive function of human beings, in which motion of hands preceded the virtual moving target in visual tracking experiments. To study the roles of the positional-error correction mechanism and the prediction mechanism, we carried out an intermittently-visual tracking experiment where a circular orbit is segmented into the target-visible regions and the target-invisible regions. Main results found in this research were following. A rhythmic component appeared in the tracer velocity when the target velocity was relatively high. The period of the rhythm in the brain obtained from environmental stimuli is shortened more than 10%. The shortening of the period of rhythm in the brain accelerates the hand motion as soon as the visual information is cut-off, and causes the precedence of hand motion to the target motion. Although the precedence of the hand in the blind region is reset by the environmental information when the target enters the visible region, the hand motion precedes the target in average when the predictive mechanism dominates the error-corrective mechanism.

Surgical specimen handover from the operating theatre to laboratory-Can we improve patient safety by learning from aviation and other high-risk organisations?

PubMed

Brennan, Peter A; Brands, Marieke T; Caldwell, Lucy; Fonseca, Felipe Paiva; Turley, Nic; Foley, Susie; Rahimi, Siavash

2018-02-01

Essential communication between healthcare staff is considered one of the key requirements for both safety and quality care when patients are handed over from one clinical area to other. This is particularly important in environments such as the operating theatre and intensive care where mistakes can be devastating. Health care has learned from other high-risk organisations (HRO) such as aviation where the use of checklists and human factors awareness has virtually eliminated human error and mistakes. To our knowledge, little has been published around ways to improve pathology specimen handover following surgery, with pathology request forms often conveying the bare minimum of information to assist the laboratory staff. Furthermore, the request form might not warn staff about potential hazards. In this article, we provide a brief summary of the factors involved in human error and introduce a novel checklist that can be readily completed at the same time as the routine pathology request form. This additional measure enhances safety, can help to reduce processing and mislabelling errors and provides essential information in a structured way assisting both laboratory staff and pathologists when handling head and neck surgical specimens. © 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Reducing Wrong Patient Selection Errors: Exploring the Design Space of User Interface Techniques

PubMed Central

Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben

2014-01-01

Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients’ identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed. PMID:25954415

Association rule mining on grid monitoring data to detect error sources

NASA Astrophysics Data System (ADS)

Maier, Gerhild; Schiffers, Michael; Kranzlmueller, Dieter; Gaidioz, Benjamin

2010-04-01

Error handling is a crucial task in an infrastructure as complex as a grid. There are several monitoring tools put in place, which report failing grid jobs including exit codes. However, the exit codes do not always denote the actual fault, which caused the job failure. Human time and knowledge is required to manually trace back errors to the real fault underlying an error. We perform association rule mining on grid job monitoring data to automatically retrieve knowledge about the grid components' behavior by taking dependencies between grid job characteristics into account. Therewith, problematic grid components are located automatically and this information - expressed by association rules - is visualized in a web interface. This work achieves a decrease in time for fault recovery and yields an improvement of a grid's reliability.

Microscopic saw mark analysis: an empirical approach.

PubMed

Love, Jennifer C; Derrick, Sharon M; Wiersema, Jason M; Peters, Charles

2015-01-01

Microscopic saw mark analysis is a well published and generally accepted qualitative analytical method. However, little research has focused on identifying and mitigating potential sources of error associated with the method. The presented study proposes the use of classification trees and random forest classifiers as an optimal, statistically sound approach to mitigate the potential for error of variability and outcome error in microscopic saw mark analysis. The statistical model was applied to 58 experimental saw marks created with four types of saws. The saw marks were made in fresh human femurs obtained through anatomical gift and were analyzed using a Keyence digital microscope. The statistical approach weighed the variables based on discriminatory value and produced decision trees with an associated outcome error rate of 8.62-17.82%. © 2014 American Academy of Forensic Sciences.

Reducing wrong patient selection errors: exploring the design space of user interface techniques.

PubMed

Sopan, Awalin; Plaisant, Catherine; Powsner, Seth; Shneiderman, Ben

2014-01-01

Wrong patient selection errors are a major issue for patient safety; from ordering medication to performing surgery, the stakes are high. Widespread adoption of Electronic Health Record (EHR) and Computerized Provider Order Entry (CPOE) systems makes patient selection using a computer screen a frequent task for clinicians. Careful design of the user interface can help mitigate the problem by helping providers recall their patients' identities, accurately select their names, and spot errors before orders are submitted. We propose a catalog of twenty seven distinct user interface techniques, organized according to a task analysis. An associated video demonstrates eighteen of those techniques. EHR designers who consider a wider range of human-computer interaction techniques could reduce selection errors, but verification of efficacy is still needed.

Social deviance activates the brain's error-monitoring system.

PubMed

Kim, Bo-Rin; Liss, Alison; Rao, Monica; Singer, Zachary; Compton, Rebecca J

2012-03-01

Social psychologists have long noted the tendency for human behavior to conform to social group norms. This study examined whether feedback indicating that participants had deviated from group norms would elicit a neural signal previously shown to be elicited by errors and monetary losses. While electroencephalograms were recorded, participants (N = 30) rated the attractiveness of 120 faces and received feedback giving the purported average rating made by a group of peers. The feedback was manipulated so that group ratings either were the same as a participant's rating or deviated by 1, 2, or 3 points. Feedback indicating deviance from the group norm elicited a feedback-related negativity, a brainwave signal known to be elicited by objective performance errors and losses. The results imply that the brain treats deviance from social norms as an error.

Federal Government Information Systems Security Management and Governance Are Pacing Factors for Innovation

ERIC Educational Resources Information Center

Edwards, Gregory

2011-01-01

Security incidents resulting from human error or subversive actions have caused major financial losses, reduced business productivity or efficiency, and threatened national security. Some research suggests that information system security frameworks lack emphasis on human involvement as a significant cause for security problems in a rapidly…

Space Station Human Factors Research Review. Volume 4: Inhouse Advanced Development and Research

NASA Technical Reports Server (NTRS)

Tanner, Trieve (Editor); Clearwater, Yvonne A. (Editor); Cohen, Marc M. (Editor)

1988-01-01

A variety of human factors studies related to space station design are presented. Subjects include proximity operations and window design, spatial perceptual issues regarding displays, image management, workload research, spatial cognition, virtual interface, fault diagnosis in orbital refueling, and error tolerance and procedure aids.

The Correlation between Sex, Age, Educational Background, and Hours of Service on Vigilance Level of ATC Officers in Air Nav Surabaya, Indonesia

ERIC Educational Resources Information Center

Saleh, Lalu Muhammad; Suwandi, Tjipto; Hamidah

2016-01-01

The vigilance of an Air Traffic Control (ATC) officer determines aviation safety. The number of aviation accidents tends to be increasing in recent years. Aviation accidents may be caused by human errors (i.e. errors made by pilot or ATC officer) or unsafe work condition. Sex, age, educational background, and hours of service might affect…

Using a Hybrid Model to Forecast the Prevalence of Schistosomiasis in Humans

PubMed Central

Zhou, Lingling; Xia, Jing; Yu, Lijing; Wang, Ying; Shi, Yun; Cai, Shunxiang; Nie, Shaofa

2016-01-01

Background: We previously proposed a hybrid model combining both the autoregressive integrated moving average (ARIMA) and the nonlinear autoregressive neural network (NARNN) models in forecasting schistosomiasis. Our purpose in the current study was to forecast the annual prevalence of human schistosomiasis in Yangxin County, using our ARIMA-NARNN model, thereby further certifying the reliability of our hybrid model. Methods: We used the ARIMA, NARNN and ARIMA-NARNN models to fit and forecast the annual prevalence of schistosomiasis. The modeling time range included was the annual prevalence from 1956 to 2008 while the testing time range included was from 2009 to 2012. The mean square error (MSE), mean absolute error (MAE) and mean absolute percentage error (MAPE) were used to measure the model performance. We reconstructed the hybrid model to forecast the annual prevalence from 2013 to 2016. Results: The modeling and testing errors generated by the ARIMA-NARNN model were lower than those obtained from either the single ARIMA or NARNN models. The predicted annual prevalence from 2013 to 2016 demonstrated an initial decreasing trend, followed by an increase. Conclusions: The ARIMA-NARNN model can be well applied to analyze surveillance data for early warning systems for the control and elimination of schistosomiasis. PMID:27023573

A neural network for noise correlation classification

NASA Astrophysics Data System (ADS)

Paitz, Patrick; Gokhberg, Alexey; Fichtner, Andreas

2018-02-01

We present an artificial neural network (ANN) for the classification of ambient seismic noise correlations into two categories, suitable and unsuitable for noise tomography. By using only a small manually classified data subset for network training, the ANN allows us to classify large data volumes with low human effort and to encode the valuable subjective experience of data analysts that cannot be captured by a deterministic algorithm. Based on a new feature extraction procedure that exploits the wavelet-like nature of seismic time-series, we efficiently reduce the dimensionality of noise correlation data, still keeping relevant features needed for automated classification. Using global- and regional-scale data sets, we show that classification errors of 20 per cent or less can be achieved when the network training is performed with as little as 3.5 per cent and 16 per cent of the data sets, respectively. Furthermore, the ANN trained on the regional data can be applied to the global data, and vice versa, without a significant increase of the classification error. An experiment where four students manually classified the data, revealed that the classification error they would assign to each other is substantially larger than the classification error of the ANN (>35 per cent). This indicates that reproducibility would be hampered more by human subjectivity than by imperfections of the ANN.

Error, blame, and the law in health care--an antipodean perspective.

PubMed

Runciman, William B; Merry, Alan F; Tito, Fiona

2003-06-17

Patients are frequently harmed by problems arising from the health care process itself. Addressing these problems requires understanding the role of errors, violations, and system failures in their genesis. Problem-solving is inhibited by a tendency to blame those involved, often inappropriately. This has been aggravated by the need to attribute blame before compensation can be obtained through tort and the human failing of attributing blame simply because there has been a serious outcome. Blaming and punishing for errors that are made by well-intentioned people working in the health care system drives the problem of iatrogenic harm underground and alienates people who are best placed to prevent such problems from recurring. On the other hand, failure to assign blame when it is due is also undesirable and erodes trust in the medical profession. Understanding the distinction between blameworthy behavior and inevitable human errors and appreciating the systemic factors that underlie most failures in complex systems are essential for the response to a harmed patient to be informed, fair, and effective in improving safety. It is important to meet society's needs to blame and exact retribution when appropriate. However, this should not be a prerequisite for compensation, which should be appropriately structured, fair, timely, and, ideally, properly funded as an intrinsic part of health care and social security systems.

Enhanced Oceanic Operations Human-In-The-Loop In-Trail Procedure Validation Simulation Study

NASA Technical Reports Server (NTRS)

Murdoch, Jennifer L.; Bussink, Frank J. L.; Chamberlain, James P.; Chartrand, Ryan C.; Palmer, Michael T.; Palmer, Susan O.

2008-01-01

The Enhanced Oceanic Operations Human-In-The-Loop In-Trail Procedure (ITP) Validation Simulation Study investigated the viability of an ITP designed to enable oceanic flight level changes that would not otherwise be possible. Twelve commercial airline pilots with current oceanic experience flew a series of simulated scenarios involving either standard or ITP flight level change maneuvers and provided subjective workload ratings, assessments of ITP validity and acceptability, and objective performance measures associated with the appropriate selection, request, and execution of ITP flight level change maneuvers. In the majority of scenarios, subject pilots correctly assessed the traffic situation, selected an appropriate response (i.e., either a standard flight level change request, an ITP request, or no request), and executed their selected flight level change procedure, if any, without error. Workload ratings for ITP maneuvers were acceptable and not substantially higher than for standard flight level change maneuvers, and, for the majority of scenarios and subject pilots, subjective acceptability ratings and comments for ITP were generally high and positive. Qualitatively, the ITP was found to be valid and acceptable. However, the error rates for ITP maneuvers were higher than for standard flight level changes, and these errors may have design implications for both the ITP and the study's prototype traffic display. These errors and their implications are discussed.

Human factors in aviation crashes involving older pilots.

PubMed

Li, Guohua; Baker, Susan P; Lamb, Margaret W; Grabowski, Jurek G; Rebok, George W

2002-02-01

Pilot errors are recognized as a contributing factor in as many as 80% of aviation crashes. Experimental studies using flight simulators indicate that due to decreased working memory capacity, older pilots are outperformed by their younger counterparts in communication tasks and flight summary scores. This study examines age-related differences in crash circumstances and pilot errors in a sample of pilots who flew commuter aircraft or air taxis and who were involved in airplane or helicopter crashes. A historical cohort of 3306 pilots who in 1987 flew commuter aircraft or air taxis and were 45-54 yr of age was constructed using the Federal Aviation Administration's airmen information system. Crash records of the study subjects for the years 1983-1997 were obtained from the National Transportation Safety Board (NTSB) by matching name and date of birth. NTSB's investigation reports were reviewed to identify pilot errors and other contributing factors. Comparisons of crash circumstances and human factors were made between pilots aged 40-49 yr and pilots aged 50-63 yr. A total of 165 crash records were studied, with 52% of these crashes involving pilots aged 50-63 yr. Crash circumstances, such as time and location of crash, type and phase of flight, and weather conditions, were similar between the two age groups. Pilot error was a contributing factor in 73% of the crashes involving younger pilots and in 69% of the crashes involving older pilots (p = 0.50). Age-related differences in the pattern of pilot errors were statistically insignificant. Overall, 23% of pilot errors were attributable to inattentiveness, 20% to flawed decisions, 18% to mishandled aircraft kinetics, and 18% to mishandled wind/runway conditions. Neither crash circumstances nor the prevalence and patterns of pilot errors appear to change significantly as age increases from the 40s to the 50s and early 60s.

Position sense at the human elbow joint measured by arm matching or pointing.

PubMed

Tsay, Anthony; Allen, Trevor J; Proske, Uwe

2016-10-01

Position sense at the human elbow joint has traditionally been measured in blindfolded subjects using a forearm matching task. Here we compare position errors in a matching task with errors generated when the subject uses a pointer to indicate the position of a hidden arm. Evidence from muscle vibration during forearm matching supports a role for muscle spindles in position sense. We have recently shown using vibration, as well as muscle conditioning, which takes advantage of muscle's thixotropic property, that position errors generated in a forearm pointing task were not consistent with a role by muscle spindles. In the present study we have used a form of muscle conditioning, where elbow muscles are co-contracted at the test angle, to further explore differences in position sense measured by matching and pointing. For fourteen subjects, in a matching task where the reference arm had elbow flexor and extensor muscles contracted at the test angle and the indicator arm had its flexors conditioned at 90°, matching errors lay in the direction of flexion by 6.2°. After the same conditioning of the reference arm and extension conditioning of the indicator at 0°, matching errors lay in the direction of extension (5.7°). These errors were consistent with predictions based on a role by muscle spindles in determining forearm matching outcomes. In the pointing task subjects moved a pointer to align it with the perceived position of the hidden arm. After conditioning of the reference arm as before, pointing errors all lay in a more extended direction than the actual position of the arm by 2.9°-7.3°, a distribution not consistent with a role by muscle spindles. We propose that in pointing muscle spindles do not play the major role in signalling limb position that they do in matching, but that other sources of sensory input should be given consideration, including afferents from skin and joint.

Independent oscillatory patterns determine performance fluctuations in children with attention deficit/hyperactivity disorder.

PubMed

Yordanova, Juliana; Albrecht, Björn; Uebel, Henrik; Kirov, Roumen; Banaschewski, Tobias; Rothenberger, Aribert; Kolev, Vasil

2011-06-01

The maintenance of stable goal-directed behaviour is a hallmark of conscious executive control in humans. Notably, both correct and error human actions may have a subconscious activation-based determination. One possible source of subconscious interference may be the default mode network that, in contrast to attentional network, manifests intrinsic oscillations at very low (<0.1 Hz) frequencies. In the present study, we analyse the time dynamics of performance accuracy to search for multisecond periodic fluctuations of error occurrence. Attentional lapses in attention deficit/hyperactivity disorder are proposed to originate from interferences from intrinsically oscillating networks. Identifying periodic error fluctuations with a frequency<0.1 Hz in patients with attention deficit/hyperactivity disorder would provide a behavioural evidence for such interferences. Performance was monitored during a visual flanker task in 92 children (7- to 16-year olds), 47 with attention deficit/hyperactivity disorder, combined type and 45 healthy controls. Using an original approach, the time distribution of error occurrence was analysed in the frequency and time-frequency domains in order to detect rhythmic periodicity. Major results demonstrate that in both patients and controls, error behaviour was characterized by multisecond rhythmic fluctuations with a period of ∼12 s, appearing with a delay after transition to task. Only in attention deficit/hyperactivity disorder, was there an additional 'pathological' oscillation of error generation, which determined periodic drops of performance accuracy each 20-30 s. Thus, in patients, periodic error fluctuations were modulated by two independent oscillatory patterns. The findings demonstrate that: (i) attentive behaviour of children is determined by multisecond regularities; and (ii) a unique additional periodicity guides performance fluctuations in patients. These observations may re-conceptualize the understanding of attentive behaviour beyond the executive top-down control and may reveal new origins of psychopathological behaviours in attention deficit/hyperactivity disorder.

Viral symbiosis and the holobiontic nature of the human genome.

PubMed

Ryan, Francis Patrick

2016-01-01

The human genome is a holobiontic union of the mammalian nuclear genome, the mitochondrial genome and large numbers of endogenized retroviral genomes. This article defines and explores this symbiogenetic pattern of evolution, looking at the implications for human genetics, epigenetics, embryogenesis, physiology and the pathogenesis of inborn errors of metabolism and many other diseases. © 2016 APMIS. Published by John Wiley & Sons Ltd.

Impact of an antiretroviral stewardship strategy on medication error rates.

PubMed

Shea, Katherine M; Hobbs, Athena Lv; Shumake, Jason D; Templet, Derek J; Padilla-Tolentino, Eimeira; Mondy, Kristin E

2018-05-02

The impact of an antiretroviral stewardship strategy on medication error rates was evaluated. This single-center, retrospective, comparative cohort study included patients at least 18 years of age infected with human immunodeficiency virus (HIV) who were receiving antiretrovirals and admitted to the hospital. A multicomponent approach was developed and implemented and included modifications to the order-entry and verification system, pharmacist education, and a pharmacist-led antiretroviral therapy checklist. Pharmacists performed prospective audits using the checklist at the time of order verification. To assess the impact of the intervention, a retrospective review was performed before and after implementation to assess antiretroviral errors. Totals of 208 and 24 errors were identified before and after the intervention, respectively, resulting in a significant reduction in the overall error rate ( p < 0.001). In the postintervention group, significantly lower medication error rates were found in both patient admissions containing at least 1 medication error ( p < 0.001) and those with 2 or more errors ( p < 0.001). Significant reductions were also identified in each error type, including incorrect/incomplete medication regimen, incorrect dosing regimen, incorrect renal dose adjustment, incorrect administration, and the presence of a major drug-drug interaction. A regression tree selected ritonavir as the only specific medication that best predicted more errors preintervention ( p < 0.001); however, no antiretrovirals reliably predicted errors postintervention. An antiretroviral stewardship strategy for hospitalized HIV patients including prospective audit by staff pharmacists through use of an antiretroviral medication therapy checklist at the time of order verification decreased error rates. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

The Causes of Errors in Clinical Reasoning: Cognitive Biases, Knowledge Deficits, and Dual Process Thinking.

PubMed

Norman, Geoffrey R; Monteiro, Sandra D; Sherbino, Jonathan; Ilgen, Jonathan S; Schmidt, Henk G; Mamede, Silvia

2017-01-01

Contemporary theories of clinical reasoning espouse a dual processing model, which consists of a rapid, intuitive component (Type 1) and a slower, logical and analytical component (Type 2). Although the general consensus is that this dual processing model is a valid representation of clinical reasoning, the causes of diagnostic errors remain unclear. Cognitive theories about human memory propose that such errors may arise from both Type 1 and Type 2 reasoning. Errors in Type 1 reasoning may be a consequence of the associative nature of memory, which can lead to cognitive biases. However, the literature indicates that, with increasing expertise (and knowledge), the likelihood of errors decreases. Errors in Type 2 reasoning may result from the limited capacity of working memory, which constrains computational processes. In this article, the authors review the medical literature to answer two substantial questions that arise from this work: (1) To what extent do diagnostic errors originate in Type 1 (intuitive) processes versus in Type 2 (analytical) processes? (2) To what extent are errors a consequence of cognitive biases versus a consequence of knowledge deficits?The literature suggests that both Type 1 and Type 2 processes contribute to errors. Although it is possible to experimentally induce cognitive biases, particularly availability bias, the extent to which these biases actually contribute to diagnostic errors is not well established. Educational strategies directed at the recognition of biases are ineffective in reducing errors; conversely, strategies focused on the reorganization of knowledge to reduce errors have small but consistent benefits.

[Improving blood safety: errors management in transfusion medicine].

PubMed

Bujandrić, Nevenka; Grujić, Jasmina; Krga-Milanović, Mirjana

2014-01-01

The concept of blood safety includes the entire transfusion chain starting with the collection of blood from the blood donor, and ending with blood transfusion to the patient. The concept involves quality management system as the systematic monitoring of adverse reactions and incidents regarding the blood donor or patient. Monitoring of near-miss errors show the critical points in the working process and increase transfusion safety. The aim of the study was to present the analysis results of adverse and unexpected events in transfusion practice with a potential risk to the health of blood donors and patients. One-year retrospective study was based on the collection, analysis and interpretation of written reports on medical errors in the Blood Transfusion Institute of Vojvodina. Errors were distributed according to the type, frequency and part of the working process where they occurred. Possible causes and corrective actions were described for each error. The study showed that there were not errors with potential health consequences for the blood donor/patient. Errors with potentially damaging consequences for patients were detected throughout the entire transfusion chain. Most of the errors were identified in the preanalytical phase. The human factor was responsible for the largest number of errors. Error reporting system has an important role in the error management and the reduction of transfusion-related risk of adverse events and incidents. The ongoing analysis reveals the strengths and weaknesses of the entire process and indicates the necessary changes. Errors in transfusion medicine can be avoided in a large percentage and prevention is cost-effective, systematic and applicable.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Herberger, Sarah M.; Boring, Ronald L.

Abstract Objectives: This paper discusses the differences between classical human reliability analysis (HRA) dependence and the full spectrum of probabilistic dependence. Positive influence suggests an error increases the likelihood of subsequent errors or success increases the likelihood of subsequent success. Currently the typical method for dependence in HRA implements the Technique for Human Error Rate Prediction (THERP) positive dependence equations. This assumes that the dependence between two human failure events varies at discrete levels between zero and complete dependence (as defined by THERP). Dependence in THERP does not consistently span dependence values between 0 and 1. In contrast, probabilistic dependencemore » employs Bayes Law, and addresses a continuous range of dependence. Methods: Using the laws of probability, complete dependence and maximum positive dependence do not always agree. Maximum dependence is when two events overlap to their fullest amount. Maximum negative dependence is the smallest amount that two events can overlap. When the minimum probability of two events overlapping is less than independence, negative dependence occurs. For example, negative dependence is when an operator fails to actuate Pump A, thereby increasing his or her chance of actuating Pump B. The initial error actually increases the chance of subsequent success. Results: Comparing THERP and probability theory yields different results in certain scenarios; with the latter addressing negative dependence. Given that most human failure events are rare, the minimum overlap is typically 0. And when the second event is smaller than the first event the max dependence is less than 1, as defined by Bayes Law. As such alternative dependence equations are provided along with a look-up table defining the maximum and maximum negative dependence given the probability of two events. Conclusions: THERP dependence has been used ubiquitously for decades, and has provided approximations of the dependencies between two events. Since its inception, computational abilities have increased exponentially, and alternative approaches that follow the laws of probability dependence need to be implemented. These new approaches need to consider negative dependence and identify when THERP output is not appropriate.« less

A predictive model of nuclear power plant crew decision-making and performance in a dynamic simulation environment

NASA Astrophysics Data System (ADS)

Coyne, Kevin Anthony

The safe operation of complex systems such as nuclear power plants requires close coordination between the human operators and plant systems. In order to maintain an adequate level of safety following an accident or other off-normal event, the operators often are called upon to perform complex tasks during dynamic situations with incomplete information. The safety of such complex systems can be greatly improved if the conditions that could lead operators to make poor decisions and commit erroneous actions during these situations can be predicted and mitigated. The primary goal of this research project was the development and validation of a cognitive model capable of simulating nuclear plant operator decision-making during accident conditions. Dynamic probabilistic risk assessment methods can improve the prediction of human error events by providing rich contextual information and an explicit consideration of feedback arising from man-machine interactions. The Accident Dynamics Simulator paired with the Information, Decision, and Action in a Crew context cognitive model (ADS-IDAC) shows promise for predicting situational contexts that might lead to human error events, particularly knowledge driven errors of commission. ADS-IDAC generates a discrete dynamic event tree (DDET) by applying simple branching rules that reflect variations in crew responses to plant events and system status changes. Branches can be generated to simulate slow or fast procedure execution speed, skipping of procedure steps, reliance on memorized information, activation of mental beliefs, variations in control inputs, and equipment failures. Complex operator mental models of plant behavior that guide crew actions can be represented within the ADS-IDAC mental belief framework and used to identify situational contexts that may lead to human error events. This research increased the capabilities of ADS-IDAC in several key areas. The ADS-IDAC computer code was improved to support additional branching events and provide a better representation of the IDAC cognitive model. An operator decision-making engine capable of responding to dynamic changes in situational context was implemented. The IDAC human performance model was fully integrated with a detailed nuclear plant model in order to realistically simulate plant accident scenarios. Finally, the improved ADS-IDAC model was calibrated, validated, and updated using actual nuclear plant crew performance data. This research led to the following general conclusions: (1) A relatively small number of branching rules are capable of efficiently capturing a wide spectrum of crew-to-crew variabilities. (2) Compared to traditional static risk assessment methods, ADS-IDAC can provide a more realistic and integrated assessment of human error events by directly determining the effect of operator behaviors on plant thermal hydraulic parameters. (3) The ADS-IDAC approach provides an efficient framework for capturing actual operator performance data such as timing of operator actions, mental models, and decision-making activities.

Wings: A New Paradigm in Human-Centered Design

NASA Technical Reports Server (NTRS)

Schutte, Paul C.

1997-01-01

Many aircraft accidents/incidents investigations cite crew error as a causal factor (Boeing Commercial Airplane Group 1996). Human factors experts suggest that crew error has many underlying causes and should be the start of an accident investigation and not the end. One of those causes, the flight deck design, is correctable. If a flight deck design does not accommodate the human's unique abilities and deficits, crew error may simply be the manifestation of this mismatch. Pilots repeatedly report that they are "behind the aircraft" , i.e., they do not know what the automated aircraft is doing or how the aircraft is doing it until after the fact. Billings (1991) promotes the concept of "human-centered automation"; calling on designers to allocate appropriate control and information to the human. However, there is much ambiguity regarding what it mean's to be human-centered. What often are labeled as "human-centered designs" are actually designs where a human factors expert has been involved in the design process or designs where tests have shown that humans can operate them. While such designs may be excellent, they do not represent designs that are systematically produced according to some set of prescribed methods and procedures. This paper describes a design concept, called Wings, that offers a clearer definition for human-centered design. This new design concept is radically different from current design processes in that the design begins with the human and uses the human body as a metaphor for designing the aircraft. This is not because the human is the most important part of the aircraft (certainly the aircraft would be useless without lift and thrust), but because he is the least understood, the least programmable, and one of the more critical elements. The Wings design concept has three properties: a reversal in the design process, from aerodynamics-, structures-, and propulsion-centered to truly human-centered; a design metaphor that guides function allocation and control and display design; and a deliberate distinction between two fundamental functions of design, to complement and to interpret human performance. The complementary function extends the human's capabilities beyond his or her current limitations - this includes sensing, computation, memory, physical force, and human decision making styles and skills. The interpretive (or hermeneutic, Hollnagel 1991) function translates information, functionality, and commands between the human and the aircraft. The Wings design concept allows the human to remain aware of the aircraft through natural interpretation. It also affords great improvements in system performance by maximizing the human's natural abilities and complementing the human's skills in a natural way. This paper will discuss the Wings design concept by describing the reversal in the traditional design process, the function allocation strategy of Wings, and the functions of complementing and interpreting the human.