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Author: Ferdinando Restina
Publisher: Lulu.com
ISBN: 0244680132
Category : Reference
Languages : en
Pages : 314
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Book Description
WHAT COMMON FACTORS CONNECT THE DEATH OF MARY SANDERS DURING A SIMPLE SURGICAL INTERVENTION, CHERNOBYL NUCLEAR DISASTER, AND THE COSTA CONCORDIA SHIPWRECK? WAS IT A FATAL MINDSET, DEFECTIVE EQUIPMENT, AN ACT OF DESTINY OR...' IT IS THE HUMAN ERROR THE THREAD THAT BINDS THESE (AND MANY OTHER) TRAGIC EVENTS. HOW TO BEST PREVENT, MANAGE AND MITIGATE ITS EFFECTS AND CONSEQUENCES IS THE SUBJECT OF STUDY BY CPT. FERDINANDO RESTINA.
Author: Ferdinando Restina
Publisher: Lulu.com
ISBN: 0244680132
Category : Reference
Languages : en
Pages : 314
Get Book Here
Book Description
WHAT COMMON FACTORS CONNECT THE DEATH OF MARY SANDERS DURING A SIMPLE SURGICAL INTERVENTION, CHERNOBYL NUCLEAR DISASTER, AND THE COSTA CONCORDIA SHIPWRECK? WAS IT A FATAL MINDSET, DEFECTIVE EQUIPMENT, AN ACT OF DESTINY OR...' IT IS THE HUMAN ERROR THE THREAD THAT BINDS THESE (AND MANY OTHER) TRAGIC EVENTS. HOW TO BEST PREVENT, MANAGE AND MITIGATE ITS EFFECTS AND CONSEQUENCES IS THE SUBJECT OF STUDY BY CPT. FERDINANDO RESTINA.
Author: Marilyn Sue Bogner
Publisher: CRC Press
ISBN: 1351440209
Category : Technology & Engineering
Languages : en
Pages : 424
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Book Description
This edited collection of articles addresses aspects of medical care in which human error is associated with unanticipated adverse outcomes. For the purposes of this book, human error encompasses mismanagement of medical care due to: * inadequacies or ambiguity in the design of a medical device or institutional setting for the delivery of medical care; * inappropriate responses to antagonistic environmental conditions such as crowding and excessive clutter in institutional settings, extremes in weather, or lack of power and water in a home or field setting; * cognitive errors of omission and commission precipitated by inadequate information and/or situational factors -- stress, fatigue, excessive cognitive workload. The first to address the subject of human error in medicine, this book considers the topic from a problem oriented, systems perspective; that is, human error is considered not as the source of the problem, but as a flag indicating that a problem exists. The focus is on the identification of the factors within the system in which an error occurs that contribute to the problem of human error. As those factors are identified, efforts to alleviate them can be instituted and reduce the likelihood of error in medical care. Human error occurs in all aspects of human activity and can have particularly grave consequences when it occurs in medicine. Nearly everyone at some point in life will be the recipient of medical care and has the possibility of experiencing the consequences of medical error. The consideration of human error in medicine is important because of the number of people that are affected, the problems incurred by such error, and the societal impact of such problems. The cost of those consequences to the individuals involved in medical error, both in the health care providers' concern and the patients' emotional and physical pain, the cost of care to alleviate the consequences of the error, and the cost to society in dollars and in lost personal contributions, mandates consideration of ways to reduce the likelihood of human error in medicine. The chapters were written by leaders in a variety of fields, including psychology, medicine, engineering, cognitive science, human factors, gerontology, and nursing. Their experience was gained through actual hands-on provision of medical care and/or research into factors contributing to error in such care. Because of the experience of the chapter authors, their systematic consideration of the issues in this book affords the reader an insightful, applied approach to human error in medicine -- an approach fortified by academic discipline.
Author: Sidney Dekker
Publisher: Routledge
ISBN: 1351786032
Category : Social Science
Languages : en
Pages : 137
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Book Description
This title was first published in 2002: This field guide assesses two views of human error - the old view, in which human error becomes the cause of an incident or accident, or the new view, in which human error is merely a symptom of deeper trouble within the system. The two parts of this guide concentrate on each view, leading towards an appreciation of the new view, in which human error is the starting point of an investigation, rather than its conclusion. The second part of this guide focuses on the circumstances which unfold around people, which causes their assessments and actions to change accordingly. It shows how to "reverse engineer" human error, which, like any other componant, needs to be put back together in a mishap investigation.
Author: David Woods
Publisher: CRC Press
ISBN: 1317175530
Category : Technology & Engineering
Languages : en
Pages : 495
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Book Description
Human error is cited over and over as a cause of incidents and accidents. The result is a widespread perception of a 'human error problem', and solutions are thought to lie in changing the people or their role in the system. For example, we should reduce the human role with more automation, or regiment human behavior by stricter monitoring, rules or procedures. But in practice, things have proved not to be this simple. The label 'human error' is prejudicial and hides much more than it reveals about how a system functions or malfunctions. This book takes you behind the human error label. Divided into five parts, it begins by summarising the most significant research results. Part 2 explores how systems thinking has radically changed our understanding of how accidents occur. Part 3 explains the role of cognitive system factors - bringing knowledge to bear, changing mindset as situations and priorities change, and managing goal conflicts - in operating safely at the sharp end of systems. Part 4 studies how the clumsy use of computer technology can increase the potential for erroneous actions and assessments in many different fields of practice. And Part 5 tells how the hindsight bias always enters into attributions of error, so that what we label human error actually is the result of a social and psychological judgment process by stakeholders in the system in question to focus on only a facet of a set of interacting contributors. If you think you have a human error problem, recognize that the label itself is no explanation and no guide to countermeasures. The potential for constructive change, for progress on safety, lies behind the human error label.
Author: Sidney Dekker
Publisher: CRC Press
ISBN: 1410612066
Category : Technology & Engineering
Languages : en
Pages : 233
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Book Description
Ten Questions About Human Error asks the type of questions frequently posed in incident and accident investigations, people's own practice, managerial and organizational settings, policymaking, classrooms, Crew Resource Management Training, and error research. It is one installment in a larger transformation that has begun to identify both deep-rooted constraints and new leverage points of views of human factors and system safety. The ten questions about human error are not just questions about human error as a phenomenon, but also about human factors and system safety as disciplines, and where they stand today. In asking these questions and sketching the answers to them, this book attempts to show where current thinking is limited--where vocabulary, models, ideas, and notions are constraining progress. This volume looks critically at the answers human factors would typically provide and compares/contrasts them with current research insights. Each chapter provides directions for new ideas and models that could perhaps better cope with the complexity of the problems facing human error today. As such, this book can be used as a supplement for a variety of human factors courses.
Author: Douglas A. Wiegmann
Publisher: Routledge
ISBN: 1351962353
Category : Technology & Engineering
Languages : en
Pages : 174
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Book Description
Human error is implicated in nearly all aviation accidents, yet most investigation and prevention programs are not designed around any theoretical framework of human error. Appropriate for all levels of expertise, the book provides the knowledge and tools required to conduct a human error analysis of accidents, regardless of operational setting (i.e. military, commercial, or general aviation). The book contains a complete description of the Human Factors Analysis and Classification System (HFACS), which incorporates James Reason's model of latent and active failures as a foundation. Widely disseminated among military and civilian organizations, HFACS encompasses all aspects of human error, including the conditions of operators and elements of supervisory and organizational failure. It attracts a very broad readership. Specifically, the book serves as the main textbook for a course in aviation accident investigation taught by one of the authors at the University of Illinois. This book will also be used in courses designed for military safety officers and flight surgeons in the U.S. Navy, Army and the Canadian Defense Force, who currently utilize the HFACS system during aviation accident investigations. Additionally, the book has been incorporated into the popular workshop on accident analysis and prevention provided by the authors at several professional conferences world-wide. The book is also targeted for students attending Embry-Riddle Aeronautical University which has satellite campuses throughout the world and offers a course in human factors accident investigation for many of its majors. In addition, the book will be incorporated into courses offered by Transportation Safety International and the Southern California Safety Institute. Finally, this book serves as an excellent reference guide for many safety professionals and investigators already in the field.
Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473
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Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Author: Carl Sandom
Publisher: IET
ISBN: 0863413293
Category : Technology & Engineering
Languages : en
Pages : 389
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Book Description
The book discusses human factors integration methodolgy and reviews the issues that underpin consideration of key topics such as human error, automation and human reliability assesment.
Author: National Research Council
Publisher: National Academies Press
ISBN: 0309173744
Category : Technology & Engineering
Languages : en
Pages : 87
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Book Description
As part of the national effort to improve aviation safety, the Federal Aviation Administration (FAA) chartered the National Research Council to examine and recommend improvements in the aircraft certification process currently used by the FAA, manufacturers, and operators.
Author: J. T. Reason
Publisher: Ashgate Publishing, Ltd.
ISBN: 9780754674009
Category : Transportation
Languages : en
Pages : 320
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Book Description
The Human Contribution is vital reading for all professionals in high-consequence environments and for managers of any complex system. The book draws its illustrative material from a wide variety of hazardous domains, with the emphasis on healthcare reflecting the author's focus on patient safety over the last decade. All students of human factors - however seasoned - will also find it an invaluable and thought-provoking read.
