Human Reliability and Error in Medical System (Industrial and Systems Engineering, 2)

✍ Scribed by B. S. Dhillon

• Publisher: World Scientific Pub Co Inc
• Year: 2003
• Tongue: English
• Leaves: 233
• Edition: 1
• Category: Library

✦ Synopsis

Human reliability and error have become a very important issue in health care, owing to the vast number of associated deaths each year. For example, according to the findings of the Institute of Medicine in 1999, around 100000 Americans die each year because of human error. This makes human error in health care the eighth leading cause of deaths in the US. Moreover, the total annual national cost of the medical errors is estimated at between USD17 billion and USD37.6 billion. There are very few books on this subject, and none of them covers it at a significant depth. The need for a book presenting the basics of human reliability, human factors and comprehensive information on error in medical systems is essential. This book meets that need.

✦ Table of Contents

Contents......Page 8
Preface......Page 16
1.2 Medical Error-Related Facts and Figures......Page 19
1.3 Terms and Definitions......Page 21
1.4.1 Books......Page 22
1.4.2 Journals......Page 23
1.4.4 Organizations......Page 24
1.5 Scope of the Book......Page 25
References......Page 26
2.2 Sets and Boolean Algebra Laws......Page 29
2.3 Probability Definition and Properties......Page 30
2.4.1 Binomial Distribution......Page 33
2.4.2 Poisson Distribution......Page 34
2.4.3 Geometric Distribution......Page 35
2.5 Continuous Random Variables and Probability Distributions......Page 36
2.5.1 Exponential Distribution......Page 37
2.5.2 Rayleigh Distribution......Page 38
2.5.3 Weibull Distribution......Page 39
2.5.5 Gamma Distribution......Page 40
2.6 Laplace Transform Definition and Final Value Theorem......Page 41
2.7 Differential Equation Solution......Page 42
Problems......Page 43
References......Page 44
3.1 Introduction......Page 47
3.2 Man-Machine System Types and Comparisons......Page 48
3.3.1 Typical Human Behaviors and the Corresponding Design Considerations......Page 49
3.4.1 Sight......Page 51
3.4.2 Noise......Page 52
3.4.4 Vibration......Page 53
3.5 Human Body Measurements......Page 54
3.6.1 Character Height Estimation Formula I......Page 56
3.6.3 Noise Reduction Estimation Formula......Page 57
3.6.4 Rest Period Estimation Formula......Page 58
3.7 Human Factors Checklist and Guidelines......Page 59
3.8 Human Factors-Related Data Sources and Useful Publications on Human Factors Data......Page 60
3.8.1 Useful Publications on Human Factors Data......Page 61
Problems......Page 62
References......Page 63
4.1 Introduction......Page 65
4.2 Human Performance Characteristics Occupational Stressors General Stress Factors and Human Operator Stress Characteristics......Page 66
4.3.1 Human Performance Reliability Function......Page 68
4.3.2 Human Performance Correctability Function......Page 70
4.4.1 The Throughput Ratio Method......Page 72
4.4.2 Pontecorvo Method......Page 73
4.4.3 Personnel Reliability Index Method......Page 75
4.5 Human Error Occurrence Reasons and Its Consequences......Page 77
4.7 Human Error Analysis Models......Page 78
4.7.2 Model II......Page 79
References......Page 83
5.1 Introduction......Page 85
5.2 Failure Modes and Effect Analysis (FMEA)......Page 86
5.3 Root Cause Analysis (RCA)......Page 88
5.3.1 RCA Softwares......Page 89
5.4 Fault Tree Analysis (FTA)......Page 90
5.4.1 Fault Tree Symbols and Steps for Performing FTA......Page 91
5.4.2 Probability Evaluation of Fault Trees......Page 92
5.5 Cause and Effect Diagram (CAED)......Page 94
5.6 Hazard Operability Study (HAZOP)......Page 95
5.7 Probability Tree Method......Page 96
5.8 Error-Cause Removal Program (ECRP)......Page 99
5.10 Markov Method......Page 100
Problems......Page 103
References......Page 104
6.1 Introduction......Page 107
6.2 Medication Error Facts Figures and Examples......Page 108
6.3 Types and Causes of Medication Error and Medication Use Processes......Page 109
6.4 Medication Errors in Hospitals......Page 112
6.5.1 Use of Information Technology for Reducing Medication Errors in Hospitals......Page 114
6.5.3 General Guidelines for Reducing Medication Errors......Page 116
6.6 Medication Error-Related Studies......Page 117
References......Page 119
7.1 Introduction......Page 123
7.3 Frequent Anesthesia Errors and Their Causes and Modes of Human Error in Anesthesia......Page 124
7.4 Anesthesiologist Decision Making Model......Page 129
7.5.1 Method I......Page 131
7.5.2 Method II......Page 132
7.5.3 Method III......Page 133
7.6 Anesthesia Error-Related Studies......Page 134
Problems......Page 135
References......Page 136
8.1 Introduction......Page 139
8.2 Human Error in Intensive Care Units......Page 140
8.3 Human Error in Emergency Medicine......Page 141
8.4 Human Error in Operating Rooms......Page 142
8.5 Human Error in Image Interpretation Laboratory Testing Medical Technology Use and Radiotherapy......Page 145
8.6 General Guidelines for Preventing Medical Errors......Page 146
8.7 Human Error Cost in Medical System......Page 147
8.7.1 Health Care Human Error-Related Cost Studies......Page 148
8.7.2 Health Care Human Error Cost Estimation Models......Page 149
References......Page 150
9.1 Introduction......Page 153
9.2 Facts and Figures......Page 154
9.3 Human Error Causing User-Interface Design Problems Medical Devices with a High Incidence of Human Errors and Medical Device-Associated Operator Errors......Page 155
9.4 An Approach to Human Factors in the Development Process of Medical Devices for Reducing Human Errors Areas for Questions in Developing an Effective Medical Device Design and Characteristics of Well-Designed Medical Devices......Page 156
9.5 Rules of Thumb for Device Control/Display Arrangement and Design Installation Software Design and Alarms with Respect to Users......Page 158
9.5.2 Rules of Thumb for Device Installation to Avoid User Errors......Page 159
9.5.4 Rules of Thumb for Device Related Alarms......Page 160
9.6 Evaluating Medical Devices Prior to Purchase and Already-Purchased with Respect to Human Factors and Practical General Guidelines for Alleviating Device- Interface Design Problems......Page 161
9.7 Human Error Analysis Methods for Medical Devices......Page 162
9.7.1 Failure Mode and Effects Analysis (FMEA)......Page 163
9.7.4 Force Field Analysis (FFA)......Page 164
9.7.5 Throughput Ratio Method......Page 165
9.7.6 Critical Incident Technique (CIT)......Page 166
References......Page 167
10.2 Model I: Human Performance Reliability......Page 171
10.3 Model II: Human Correctability Function......Page 174
10.4 Model III: Human Performance Reliability in Alternating Environment......Page 176
10.5 Model IV: Human Performance Reliability with Critical and Non-Critical Errors......Page 179
10.6 Model V: Human Performance Reliability with Critical and Non-Critical Errors and Corrective Action......Page 181
10.7 Model VI: Reliability Analysis of a Medical Redundant System with Human Errors......Page 184
Problems......Page 187
References......Page 188
11.1 Introduction......Page 189
11.2 Effective Event-Reporting Systems and Approaches Practiced in Existing Reporting Systems......Page 190
11.3 Review of Current Human Error-Related Health Care Reporting Systems......Page 191
11.4 Lessons from Non-Medical Near Miss Reporting Systems......Page 194
11.5 State Adverse Medical Event Reporting Systems......Page 195
11.6 Human Error Data and Sources......Page 200
11.6.2 Non-Medical Human Error Data......Page 201
11.6.3 Human Error Data Sources......Page 202
References......Page 204
A.2 Publications......Page 207
Index......Page 229