Download or read book To Err Is Human written by Institute of Medicine and published by National Academies Press. This book was released on 2000-03-01 with total page 312 pages. Available in PDF, EPUB and Kindle. Book excerpt: Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That's more than die from motor vehicle accidents, breast cancer, or AIDSâ€"three causes that receive far more public attention. Indeed, more people die annually from medication errors than from workplace injuries. Add the financial cost to the human tragedy, and medical error easily rises to the top ranks of urgent, widespread public problems. To Err Is Human breaks the silence that has surrounded medical errors and their consequenceâ€"but not by pointing fingers at caring health care professionals who make honest mistakes. After all, to err is human. Instead, this book sets forth a national agendaâ€"with state and local implicationsâ€"for reducing medical errors and improving patient safety through the design of a safer health system. This volume reveals the often startling statistics of medical error and the disparity between the incidence of error and public perception of it, given many patients' expectations that the medical profession always performs perfectly. A careful examination is made of how the surrounding forces of legislation, regulation, and market activity influence the quality of care provided by health care organizations and then looks at their handling of medical mistakes. Using a detailed case study, the book reviews the current understanding of why these mistakes happen. A key theme is that legitimate liability concerns discourage reporting of errorsâ€"which begs the question, "How can we learn from our mistakes?" Balancing regulatory versus market-based initiatives and public versus private efforts, the Institute of Medicine presents wide-ranging recommendations for improving patient safety, in the areas of leadership, improved data collection and analysis, and development of effective systems at the level of direct patient care. To Err Is Human asserts that the problem is not bad people in health careâ€"it is that good people are working in bad systems that need to be made safer. Comprehensive and straightforward, this book offers a clear prescription for raising the level of patient safety in American health care. It also explains how patients themselves can influence the quality of care that they receive once they check into the hospital. This book will be vitally important to federal, state, and local health policy makers and regulators, health professional licensing officials, hospital administrators, medical educators and students, health caregivers, health journalists, patient advocatesâ€"as well as patients themselves. First in a series of publications from the Quality of Health Care in America, a project initiated by the Institute of Medicine

Download or read book A Human Error Approach to Aviation Accident Analysis written by Douglas A. Wiegmann and published by Routledge. This book was released on 2017-12-22 with total page 174 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Human Error written by James Reason and published by Cambridge University Press. This book was released on 1990-10-26 with total page 324 pages. Available in PDF, EPUB and Kindle. Book excerpt: This 1991 book is a major theoretical integration of several previously isolated literatures looking at human error in major accidents.

Download or read book Managing the Risks of Organizational Accidents written by James Reason and published by Routledge. This book was released on 2016-01-29 with total page 272 pages. Available in PDF, EPUB and Kindle. Book excerpt: Major accidents are rare events due to the many barriers, safeguards and defences developed by modern technologies. But they continue to happen with saddening regularity and their human and financial consequences are all too often unacceptably catastrophic. One of the greatest challenges we face is to develop more effective ways of both understanding and limiting their occurrence. This lucid book presents a set of common principles to further our knowledge of the causes of major accidents in a wide variety of high-technology systems. It also describes tools and techniques for managing the risks of such organizational accidents that go beyond those currently available to system managers and safety professionals. James Reason deals comprehensively with the prevention of major accidents arising from human and organizational causes. He argues that the same general principles and management techniques are appropriate for many different domains. These include banks and insurance companies just as much as nuclear power plants, oil exploration and production companies, chemical process installations and air, sea and rail transport. Its unique combination of principles and practicalities make this seminal book essential reading for all whose daily business is to manage, audit and regulate hazardous technologies of all kinds. It is relevant to those concerned with understanding and controlling human and organizational factors and will also interest academic readers and those working in industrial and government agencies.

Download or read book Handbook of Human Factors and Ergonomics written by Gavriel Salvendy and published by John Wiley & Sons. This book was released on 2012-05-24 with total page 1754 pages. Available in PDF, EPUB and Kindle. Book excerpt: The fourth edition of the Handbook of Human Factors and Ergonomics has been completely revised and updated. This includes all existing third edition chapters plus new chapters written to cover new areas. These include the following subjects: Managing low-back disorder risk in the workplace Online interactivity Neuroergonomics Office ergonomics Social networking HF&E in motor vehicle transportation User requirements Human factors and ergonomics in aviation Human factors in ambient intelligent environments As with the earlier editions, the main purpose of this handbook is to serve the needs of the human factors and ergonomics researchers, practitioners, and graduate students. Each chapter has a strong theory and scientific base, but is heavily focused on real world applications. As such, a significant number of case studies, examples, figures, and tables are included to aid in the understanding and application of the material covered.

Download or read book Error Systems Concepts Theory and Applications written by Kaizhong Guo and published by Springer Nature. This book was released on 2020-02-29 with total page 360 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book offers a new perspective and deeper understanding of complex socioeconomic systems, and explores the laws and mechanisms of erring by revealing the system structure, i.e., the context in which errors are imbedded. It proposes a number of new concepts for the field of systems science concerning the forces affecting e.g. system structure, subsystem structures, and system elements. Given its scope, it offers an excellent reference book for researchers and other readers in the fields of systems science, management science, mathematics, fuzzy logic and sets, symbolic logic, philosophy, etc. The book can also benefit researchers and practitioners in artificial intelligence and machine learning, as various erring patterns can be identified by training intelligent machines with big data (i.e., error cases and their logic), helping to prevent or eliminate errors in a cost-effective manner.

Download or read book Error Logic Paving Pathways for Intelligent Error Identification and Management written by Shiyong Liu and published by Springer Nature. This book was released on 2023-03-07 with total page 619 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book offers a brand-new theoretical system and relevant tools for intelligently identifying errors in the decision-making process, investigating the complexities and erring mechanisms of dysfunctional socioeconomic systems, and therefore helping design error-proof systems. The error logic is invented to pioneer a new branch for the field of logic, which can be applied to various fields including mathematics, philosophy, computer science, artificial intelligence, linguistics, management science, and systems science. Researchers, postgraduates, and undergraduates in relevant fields can use it as a reference for enhancing their understanding of the tempo-spatial dynamics and transformation of errors in complicated systems. The manuscript also provides vivid and thought-provoking examples and applications to help readers understand how to apply the concepts and theory in real socioeconomic systems.

Download or read book Health Care Comes Home written by National Research Council and published by National Academies Press. This book was released on 2011-06-22 with total page 202 pages. Available in PDF, EPUB and Kindle. Book excerpt: In the United States, health care devices, technologies, and practices are rapidly moving into the home. The factors driving this migration include the costs of health care, the growing numbers of older adults, the increasing prevalence of chronic conditions and diseases and improved survival rates for people with those conditions and diseases, and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as in its quality and cost. Health Care Comes Home reviews the state of current knowledge and practice about many aspects of health care in residential settings and explores the short- and long-term effects of emerging trends and technologies. By evaluating existing systems, the book identifies design problems and imbalances between technological system demands and the capabilities of users. Health Care Comes Home recommends critical steps to improve health care in the home. The book's recommendations cover the regulation of health care technologies, proper training and preparation for people who provide in-home care, and how existing housing can be modified and new accessible housing can be better designed for residential health care. The book also identifies knowledge gaps in the field and how these can be addressed through research and development initiatives. Health Care Comes Home lays the foundation for the integration of human health factors with the design and implementation of home health care devices, technologies, and practices. The book describes ways in which the Agency for Healthcare Research and Quality (AHRQ), the U.S. Food and Drug Administration (FDA), and federal housing agencies can collaborate to improve the quality of health care at home. It is also a valuable resource for residential health care providers and caregivers.

Download or read book Behind Human Error written by David Woods and published by CRC Press. This book was released on 2017-09-18 with total page 495 pages. Available in PDF, EPUB and Kindle. Book excerpt: 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.

Download or read book Human System Integration in the System Development Process written by National Research Council and published by National Academies Press. This book was released on 2007-06-15 with total page 396 pages. Available in PDF, EPUB and Kindle. Book excerpt: In April 1991 BusinessWeek ran a cover story entitled, "I Can't Work This ?#!!@ Thing," about the difficulties many people have with consumer products, such as cell phones and VCRs. More than 15 years later, the situation is much the same-but at a very different level of scale. The disconnect between people and technology has had society-wide consequences in the large-scale system accidents from major human error, such as those at Three Mile Island and in Chernobyl. To prevent both the individually annoying and nationally significant consequences, human capabilities and needs must be considered early and throughout system design and development. One challenge for such consideration has been providing the background and data needed for the seamless integration of humans into the design process from various perspectives: human factors engineering, manpower, personnel, training, safety and health, and, in the military, habitability and survivability. This collection of development activities has come to be called human-system integration (HSI). Human-System Integration in the System Development Process reviews in detail more than 20 categories of HSI methods to provide invaluable guidance and information for system designers and developers.

Download or read book Human Error in Process Plant Design and Operations written by J. Robert Taylor and published by CRC Press. This book was released on 2016-01-05 with total page 318 pages. Available in PDF, EPUB and Kindle. Book excerpt: In contrast to nuclear plants and aerospace systems, human error is largely ignored in quantitative risk assessment for petroleum and chemical plants. Because of this, current risk analysis methods are able to calculate and predict only about one-third of the accidents happening in practice. Human Error in Process Plant Design and Operations: A Pra

Download or read book Communication in High Risk Environments written by Rainer Dietrich and published by Helmut Buske Verlag. This book was released on 2003-09-01 with total page 181 pages. Available in PDF, EPUB and Kindle. Book excerpt: Eine Zigarre rauchen, Zeitung lesen und sich am Kopf kratzen, das kann man gleichzeitig - und zwar mühelos, konstatiert John Searle. Ein Auto im Dunkeln in eine enge Parklücke rangieren und zugleich dem Beifahrer erklären, wo die Opernkarten sind, ist heikel und mehr als heikel, wenn die Ouvertüre schon begonnen hat. Dass die Sprachverwendung, produktiv und perzeptiv, eine anspruchsvolle kognitive Aktivität ist, zeigt sich, wenn das kognitive System gleichzeitig andere anspruchsvolle Leistungen durchführt. Dann vermindert sich die Leistung, die eine oder die andere oder beide. Die Frage nach der sprachliche Performanz unter so genannten Doppelaufgabenbedingungen ist für die Sprachforschung so spannend wie ungewohnt. Antworten darauf sind nicht nur von akademischem Interesse. Im Cockpit eines Linienjets, am Operationstisch und in der Leitwarte eines Kernkraftwerks verursacht eingeschränkte Kommunikationsleistung unmittelbare Gefahr. In diesem Heft berichten u.a. Linguisten und Psycholinguisten (Krifka, Dietrich), Human-Factors-Experten (Helmreich, Sexton), Arbeitspsychologen (Grote, Sträter) über Prinzipien der Sprachverwendung unter Aufgabendruck und Zeitdruck. Abstracts: Using Language in the Cockpit: Relationships with Workload and Performance J. Bryan Sexton & Robert L. Helmreich Few events attract as much international attention as an accident involving a commercial jumbo jet airplane. The public, the airlines, the airplane manufacturers, and particularly the friends and family of passengers demand answers. The work presented here illustrates the importance of flight deck communication in flight safety through a simulator study of how and what pilots communicate. This investigation utilized a computer-based linguistic method of text analysis as well as a micro-coding of communication content. Analyses of simulator transcripts demonstrated that several language dimensions were associated with higher performance, fewer errors, and better communication. The ways in which pilots used language varied as a function of crew position and level of workload. Additionally, language use in the first flight of a crew pairing was associated with performance in subsequent flights. Group Interaction in the Cockpit: Some Linguistic Factors Manfred Krifka, Silka Martens, and Florian Schwarz For a number of years it has been recognized that the social dynamics of group interaction is an import factor in the origin of accidents and in the way how accidents or accident-prone situations are handled in aviation (cf. Helmreich 1997a, 1997b). Factors related to interpersonal communication have been implicated in up to 80% of all aviation accidents over the past 20 years. As a reaction to this, Crew Resource Management (CRM) has been developed with the goal of rating and improving crew performance in aviation and in other fields in which professional groups interact in situations of high taskload and potential risk (cf. Helmreich ea. 1999). As far as this can be estimated at all, installing CRM techniques in the major American and European airlines has resulted in a definite improvement in the safety of commercial aviation. In spite of this success of CRM, practitioners in the field feel that, beyond the general social dynamics of group interaction, there might be potential problems relating to language and communication in such settings. In this article, we first summarize some aspects of previous research in this area. Then we report findings from a project that one of us, Manfred Krifka, has carried out, using transcripts of flight simulator sessions with pilots of a commercial American airline. We will discuss some of the problems of this project. Finally, we describe an ongoing continuation of that project that uses flight simulator sessions with pilots of a commercial German airline.

Download or read book Handbook of Human Factors and Ergonomics in Health Care and Patient Safety written by Pascale Carayon and published by CRC Press. This book was released on 2006-09-08 with total page 1012 pages. Available in PDF, EPUB and Kindle. Book excerpt: A complete resource, this handbook presents current knowledge on concepts and methods of human factors and ergonomics, and their applications to help improve quality, safety, efficiency, and effectiveness in patient care. It provides specific information on how to analyze medical errors with the fundamental goal to reduce such errors and the harm t

Download or read book Human Performance Improvement through Human Error Prevention written by BW (Ben) Marguglio and published by CRC Press. This book was released on 2021-10-28 with total page 705 pages. Available in PDF, EPUB and Kindle. Book excerpt: This book is a simulation of a live course on human performance improvement/human error prevention (HPI/HEP) created by the preeminent authority on HPI/HEP. It presents the greatest breadth of scope and specificity on this topic. This book comprises a focused, challenging human error prevention training course designed to improve understanding of error causation. It will dramatically reduce human error and repeat deviations, and it digs below the surface of issues and looks to fix the real causes of human error and mistakes. In addition, this book presents a complete seminar from the thought leader acclaimed by hundreds of clients, and includes unique principles, practices, models, and templates. Information is comprehensive and can be directly implemented. The principles and practices of human error prevention are universally applicable regardless of the type of industrial, commercial, or governmental enterprise, and regardless of the type of function performed within the enterprise. The application of the information in this book will significantly contribute to improved productivity, safety, and quality. After fully using this book, you will understand: Human error prevention/reduction terminology and definitions. The relationships among culture, beliefs, values, attitudes, behavior, results, and performance. The roles of leadership in establishing and maintaining a quality/safety-conscious work environment. The one fundamental precept explaining the importance of human error prevention/reduction. The two most critical elements of human error prevention/reduction. The three levels of barriers to human error. The four types of things in which the barriers may exist at each barrier level. The five stages of human error. The six "M"s that can emit or receive hazards activated by human error. The seven universally applicable human error causal factors. The Rule of 8 by which to prevent human error and mitigate its effects. Techniques for making barriers effective and the spectrum of barrier effectiveness. The relationship of human error prevention/reduction to the total quality/safety function. Error-inducing conditions (error traps) and behaviors for counteracting these conditions. Non-conservative and conservative thought processes and behaviors in decision-making. Coaching for preventing the recurrence of human error. Root cause analysis techniques for identifying human error causal factors. The nine types of corrective action. Human error measurement. Strategies for a human error prevention/reduction initiative. How to design, implement, and manage a human error prevention/reduction initiative.

Download or read book Handbook of Human Factors and Ergonomics written by Gavriel Salvendy and published by John Wiley & Sons. This book was released on 2012-03-13 with total page 1754 pages. Available in PDF, EPUB and Kindle. Book excerpt: The fourth edition of the Handbook of Human Factors and Ergonomics has been completely revised and updated. This includes all existing third edition chapters plus new chapters written to cover new areas. These include the following subjects: Managing low-back disorder risk in the workplace Online interactivity Neuroergonomics Office ergonomics Social networking HF&E in motor vehicle transportation User requirements Human factors and ergonomics in aviation Human factors in ambient intelligent environments As with the earlier editions, the main purpose of this handbook is to serve the needs of the human factors and ergonomics researchers, practitioners, and graduate students. Each chapter has a strong theory and scientific base, but is heavily focused on real world applications. As such, a significant number of case studies, examples, figures, and tables are included to aid in the understanding and application of the material covered.

Download or read book Advisory Circular written by United States. Federal Aviation Administration and published by . This book was released on 19?? with total page 82 pages. Available in PDF, EPUB and Kindle. Book excerpt:

Download or read book Handbook of Human Factors and Ergonomics in Health Care and Patient Safety Second Edition written by Pascale Carayon and published by CRC Press. This book was released on 2011-11-09 with total page 879 pages. Available in PDF, EPUB and Kindle. Book excerpt: The first edition of Handbook of Human Factors and Ergonomics in Health Care and Patient Safety took the medical and ergonomics communities by storm with in-depth coverage of human factors and ergonomics research, concepts, theories, models, methods, and interventions and how they can be applied in health care. Other books focus on particular human factors and ergonomics issues such as human error or design of medical devices or a specific application such as emergency medicine. This book draws on both areas to provide a compendium of human factors and ergonomics issues relevant to health care and patient safety. The second edition takes a more practical approach with coverage of methods, interventions, and applications and a greater range of domains such as medication safety, surgery, anesthesia, and infection prevention. New topics include: work schedules error recovery telemedicine workflow analysis simulation health information technology development and design patient safety management Reflecting developments and advances in the five years since the first edition, the book explores medical technology and telemedicine and puts a special emphasis on the contributions of human factors and ergonomics to the improvement of patient safety and quality of care. In order to take patient safety to the next level, collaboration between human factors professionals and health care providers must occur. This book brings both groups closer to achieving that goal.