Observed rates of surgical instrument errors point to visualization tasks as being a critically vulnerable point in sterile processing and a significant cause of lost chargeable OR minutes.

BACKGROUND: The reporting of surgical instrument errors historically relies on cumbersome, non-automated, human-dependent, data entry into a computer database that is not integrated into the electronic medical record. The limitations of these reporting systems make it difficult to accurately estimate the negative impact of surgical instrument errors on operating room efficiencies. We set out to determine the impact of surgical instrument errors on a two-hospital healthcare campus using independent observers trained in the identification of Surgical Instrument Errors. METHODS: This study was conducted in the 7 pediatric ORs at an academic healthcare campus. Direct observations were conducted over the summer of 2021 in the 7 pediatric ORs by 24 trained student observers during elective OR days. Surgical service line, error type, case type (inpatient or outpatient), and associated length of delay were recorded. RESULTS: There were 236 observed errors affecting 147 individual surgical cases. The three most common errors were Missing+ (n = 160), Broken/poorly functioning instruments (n = 44), and Tray+ (n = 13). Errors arising from failures in visualization (i.e. inspection, identification, function) accounted for 88.6% of all errors (Missing+/Broken/Bioburden). Significantly more inpatient cases (42.73%) had errors than outpatient cases (22.32%) (p = 0.0129). For cases in which data was collected on whether an error caused a delay (103), over 50% of both IP and OP cases experienced a delay. The average length of delays per case was 10.16 min. The annual lost charges in dollars for surgical instrument associated delays in chargeable minutes was estimated to be between $6,751,058.06 and $9,421,590.11. CONCLUSIONS: These data indicate that elimination of surgical instrument errors should be a major target of waste reduction. Most observed errors (88.6%) have to do with failures in the visualization required to identify, determine functionality, detect the presence of bioburden, and assemble instruments into the correct trays. To reduce these errors and associated waste, technological advances in instrument identification, inspection, and assembly will need to be made and applied to the process of sterile processing.

The effect of font boldness, noise disturbance and time pressure on human error in the context of cloud change operation.

This study investigated the number of operator errors, task completion time, and workload of subjects at different levels by imposing conditions such as focused text boldness, noise disturbance, and time pressure to simulate a realistic cloud change business process in the laboratory. Results of the study showed that the text bolding of important content reduced the number of errors, whereas noise interference increased the number of errors. Text boldness only reduced the number of corrected errors, and noise interference only increased the number of uncorrected errors. Moreover, bolding was found to have different effects on the number of errors under different noise levels and time pressure levels, with text boldness significantly reducing the number of total errors only in quiet or low time pressure states. Time pressure had no effect on cloud change task error counts, but high time pressure resulted in higher subjective workload.

Operator error is one of the main causes of service failure, and reducing operator error in cloud change operations is of practical importance. In this study, we found focused text boldness could reduce operator errors, while noise could increase the number of errors. High time pressure would lead to a high workload.

High-speed train drivers' human error under fatigue and stress: the role of situation awareness and individual differences.

Fatigue and stress are critical variables that impair railway train drivers' safety performance, and individual differences may influence these effects. This study investigates how fatigue and stress affect high-speed train drivers' human error and the role of individual differences. We hypothesised that situation awareness (SA) mediates the effects of fatigue and stress on human error, and individual differences (age and work experience) moderate these effects. We surveyed 1,391 male drivers from eight Chinese railway bureaus and used PROCESS Macro for data analysis. The results revealed that fatigue and stress increased human error, directly and indirectly through SA. Age and work experience moderated the effect of fatigue and stress on SA, respectively. Older drivers had better SA under high fatigue, while more experienced drivers had better SA under high stress. These findings can inform more tailored safety management strategies to lower human error and enhance the safety of high-speed train operations.

A cross-sectional survey of 1,391 high-speed train drivers in China indicated that fatigue and stress amplify human error by impairing situation awareness (SA). Age and work experience were observed to moderate the impact of fatigue and stress on SA, respectively. These insights guide the advancement of safety management strategies.

A generic approach to developing human factors-quality assessment tools exemplified by the warehouse error prevention tool.

This study proposes a generic approach for creating human factors-based assessment tools to enhance operational system quality by reducing errors. The approach was driven by experiences and lessons learned in creating the warehouse error prevention (WEP) tool and other system engineering tools. The generic approach consists of 1) identifying tool objectives, 2) identifying system failure modes, 3) specifying design-related quality risk factors for each failure mode, 4) designing the tool, 5) conducting user evaluations, and 6) validating the tool. The WEP tool exemplifies this approach and identifies human factors related to design flaws associated with quality risk factors in warehouse operations. The WEP tool can be used at the initial stage of design or later for process improvement and training. While this process can be adapted for various contexts, further study is necessary to support the teams in creating tools to identify design-related human factors contributing to quality issues.

This paper describes a generic approach to creating human factors­based quality assessment tools. The approach is illustrated with the Warehouse Error Prevention (WEP) tool, which is designed to help users identify HF-related quality risk factors in warehouse system designs (available for free: Setayesh et al. 2022b).

Slicing Through the Layers of Pediatric Unintentional Injury With the Swiss Cheese Model: A Topical Review.

Pediatric unintentional injury significantly burdens children, families, and society. Behavioral researchers have examined the problem for decades, identifying many risk factors and greatly enhancing knowledge of the injury antecedent process. Approaches using theories and models to guide inquiry into etiology and prevention are still needed. We offer an approach borrowed from the field of human factors to enhance understanding and prevention. We focus our exploration on an error modeling and accident investigation tool called the Swiss Cheese Model. We first introduce the basic elements of the model. Next, we apply error modeling concepts to example scenarios drawn from real unintentional incidents and discuss the implications for understanding etiology and prevention. Finally, potential future directions are discussed to illustrate paths for the advancement of injury etiology and prevention.

Complication Avoidance in Neurosurgery with Use of Intraoperative Ultrasonography.

Intraoperative ultrasonography is an extremely valuable tool for avoidance of complications during neurosurgical procedures, including resection of intracranial and spinal cord tumors, removal of spontaneous intracerebral hemorrhages and arteriovenous malformations, and ventricular access for shunt placements. Nevertheless, application of this highly useful technique may be accompanied by some challenges and difficulties, as well as human errors; thus, it requires specific knowledge and continuous training.

Defending Against Medical Error: Personal Reflections on the Legacy of John Senders.

OBJECTIVE: To honor the legacy of John Senders, a distinguished member of the Human Factors and Ergonomics Society, by a short, personal history of him, but then to honor his legacy by extending it through our own professional opinions, with an emphasis on the study of human error and its implications for healthcare systems-two topics in which he excelled. BACKGROUND: The authors are familiar with the topic and subject matter. One was a friend of Senders for over 50 years. Another was a collaborator and joint author with Senders (as well as his stepdaughter). All three authors have extensive publications in the topic areas. METHOD, RESULTS, AND CONCLUSION: The authors used personal accounts of interactions with Senders at conferences, experiences living and working with him, and a brief review of his most personal, notable publications in healthcare. The reflections indicate a strong resonance on Senders' contributions to system design that are relevant today in healthcare's most challenging period in its history.

John Senders, Human Error, and System Safety.

OBJECTIVE: I examine John Senders' work and discuss his influence on the study of error causation,error mitigation, and sociotechnical system safety. BACKGROUND: John Senders' passing calls for an evaluation of the impact of his work. METHOD: I review literature and accident investigation findings to discuss themes in Senders' work and potential associations between that work and error causation and system safety. RESULTS: Senders consistently emphasized empirical rigor and theoretical exploration in his research, with the desire to apply that work to enhance human performance. He has contributed to changing the way error has been viewed, and to developing and implementing programs and techniques to mitigate error. While a causal relationship between Senders' work and safety cannot be established, an association can be drawn between his research and efforts to mitigate error. CONCLUSION: Because of Senders' work, we have a better understanding of error causation and enhanced ways of mitigating system errors. However, new sources of error, involving advanced systems and operators' knowledge and understanding of their functionalities can, if not addressed, degrade system safety. APPLICATION: Modifications to advanced automation and operator training are suggested, and research to improve operator expertise in interacting with automated systems proposed.

A Closer Look at Warning Cues on the Sustained Attention to Response Task Performance.

OBJECTIVES: We investigated the effects of auditory cues of varying reliability levels on response inhibition performance using a target detection task to determine if external cues offer performance benefits. Further, we examined how the slope of the speed accuracy trade-off changes as a function of auditory cue reliability and used the trade-off to understand where any performance gains may be realized. BACKGROUND: Researchers have proposed that the sustained attention to response task (SART) can be used to study the mechanisms causing failures of response inhibition. External cues may mitigate the results of motor inhibition failure. The extent to which external cues can effectively aid performance depends on the level of cue reliability. METHOD: Ninety-one participants performed three SARTs with auditory cue assistance at three different levels of reliability (i.e. 0%, 60% and 100% reliable at cueing imminent No-Go stimuli). RESULTS: We observed fewer errors of commission and faster reaction time in conditions with higher cue reliability. The slope of speed-accuracy trade-off relationship was impacted by cue reliability and was not a simple linear function. CONCLUSION: Reliable auditory cues aid performance by reducing reaction time and errors of commission. Auditory cues also impact the relationship between speed and accuracy trade-off. APPLICATION: Insights of cue effectiveness at different reliability levels help people make informed decisions in developing automation interfaces or sensors based on expected performance. Reliable cues mitigate the risk of impulsive errors; however, the reliability has to be high to have a noticeable impact on the speed-accuracy trade-off.

Using HFACS to understand human error in railway dispatcher performance: a study of proactive safety inspection records.

This study analyzes 4,095 proactive safety inspection records obtained from a large dispatching centre by utilising the HFACS framework. These proactive safety inspection records offer comprehensive documentation of incidents, capturing major accidents and numerous minor discrepancies and lapses that often go unnoticed in accident reports. The analysis revealed that most incidents were attributed to unsafe actions, primarily skill-based errors and poor decision-making. Additionally, contributing factors such as adverse mental states, personal readiness, and crew resource management were found to play a significant role as preconditions for unsafe acts. Path analyses further established a significant correlation between factors such as unsafe supervision, preconditions for unsafe acts, and the occurrence of unsafe acts. In our discussion, we critically evaluate the strengths and limitations of proactive safety inspection records in safety research. Moreover, we emphasise these findings' potential to enhance safety within the railway industry.

Based on a substantial dataset comprising proactive safety inspection records of railway dispatchers rather than the incident reports utilised in prior studies, this paper presents a causal model of human error among railway dispatchers in combination with HFACS and critically evaluates the strengths and limitations of active safety inspection records.

Human Error Prediction Using Heart Rate Variability and Electroencephalography.

As human's simple tasks are being increasingly replaced by autonomous systems and robots, it is likely that the responsibility of handling more complex tasks will be more often placed on human workers. Thus, situations in which workplace tasks change before human workers become proficient at those tasks will arise more frequently due to rapid changes in business trends. Based on this background, the importance of preventing human error will become increasingly crucial. Existing studies on human error reveal how task errors are related to heart rate variability (HRV) indexes and electroencephalograph (EEG) indexes. However, in terms of preventing human error, analysis on their relationship with conditions before human error occurs (i.e., the human pre-error state) is still insufficient. This study aims at identifying biological indexes potentially useful for the detection of high-risk psychological states. As a result of correlation analysis between the number of errors in a Stroop task and the multiple HRV and EEG indexes obtained before and during the task, significant correlations were obtained with respect to several biological indexes. Specifically, we confirmed that conditions before the task are important for predicting the human error risk in high-cognitive-load tasks while conditions both before and during tasks are important in low-cognitive-load tasks.

An Attentive Blank Stare Under Simulator-induced Spatial Disorientation Events.

OBJECTIVE: This study investigated the effect of the spatial disorientation (SD) events on an attentive blank stare in the cockpit scene and demonstrated how much the flight task and visual delayed discrimination task were competing for the pilots' attention. BACKGROUND: SD in flight is the leading cause of human error-related aircraft accidents in the military, general and commercial aviation, and has been an unsolved problem since the inception of flight. In-flight safety research, visually scanning cockpit instruments, and detecting changes are critical countermeasures against SD. METHOD: Thirty male military pilots were performing a dual task involving piloting a flight simulator and visual change detection, while eye movements were obtained using an eye tracker. RESULTS: Pilots made more flight errors and spent less time gazing at the area of change in SD-conflict than in non-conflict flights. The vestibular origin SD-conflict led not only to deteriorated piloting and visual scanning but also to problems coordinating overt and covert attention, resulting in lower noticeability of visual changes despite gazing at them. CONCLUSION: Our study shows that looking at a given area in space is not a sufficient condition for effective covert attention allocation and the correct response to a visual stimulus. It seems to be important to make pilots aware of this during SD training. APPLICATION: To reduce change blindness, some strategies, such as reducing the number of secondary tasks is extremely valuable. Particular efforts should also be focused on improving the design of the aircraft cockpit by increasing the conspicuousness of critical information.

Prospective analysis of intraoperative critical incidents relevant to anaesthesia in a tertiary care teaching hospital in India.

Background and Aims: Critical incidents associated with anesthesia can affect the patient's outcome, may cause transient damage, and contribute to mortality. We aimed at recording anesthesia-related critical incidents in patients undergoing general surgical, ear, nose, and throat (ENT) and orthopedic surgical procedures in our institution. The critical incidents data were analyzed regarding the cause to establish protocols to prevent recurrences. Material and Methods: We conducted a prospective analysis of voluntarily reported perioperative critical incidents occurring in patients subjected to anesthesia over 1 year. Critical incidents were noted in terms of time (while inducing/intraoperative/while extubating), location (operating theater/recovery room) of the incident, anesthesia-related or surgery-related complications. Data collected were expressed as numbers and proportions to calculate incidence. Results: Anesthesia was administered to 5,645 patients of which 131 (2.32%) patients had critical incidents. Of these 131, 46 (35.11%) patients had more than one critical incident. A total of 216 (3.82%) critical incidents were noted. A majority of the patients were in the age range of 51-60 years. The maximum incidents occurred during the intraoperative period (35.11%) and in the operating theater (86.25%). Of the 216 incidents, 154 (71.30%) were anesthesia-related, 18 (8.33%) were surgery-related, 1 (0.46%) was patient-related and 43 (19.91%) were recovery-related. Of the 216 incidents, cardiovascular-related incidents accounted for the maximum incidents (18.05%, n = 39). Most of the events were preventable. Conclusion: The critical incident reporting system should be encouraged and protocols established to reduce the frequency and severity of these occurrences.

Towards ARTEM-IS: Design guidelines for evidence-based EEG methodology reporting tools.

As the number of EEG papers increases, so too do the number of guidelines for how to report what has been done. However, current guidelines and checklists appear to have limited adoption, as systematic reviews have shown the journal article format is highly prone to errors, ambiguities and omissions of methodological details. This is a problem for transparency in the scientific record, along with reproducibility and metascience. Following lessons learned in the high complexity fields of aviation and surgery, we conclude that new tools are needed to overcome the limitations of written methodology descriptions, and that these tools should be developed through community consultation to ensure that they have the most utility for EEG stakeholders. As a first step in tool development, we present the ARTEM-IS Statement describing what action will be needed to create an Agreed Reporting Template for Electroencephalography Methodology - International Standard (ARTEM-IS), along with ARTEM-IS Design Guidelines for developing tools that use an evidence-based approach to error reduction. We first launched the statement at the LiveMEEG conference in 2020 along with a draft of an ARTEM-IS template for public consultation. Members of the EEG community are invited to join this collective effort to create evidence-based tools that will help make the process of reporting methodology intuitive to complete and foolproof by design.

The evolution of methods to estimate the rate of medication error in anaesthesia.

The rate of medication errors in anaesthesia is a critical safety indicator but the methods to estimate this metric are imperfect. A number of factors that are difficult to control impact their incidence. Newer methods involving computerised records are improving retrospective and real-time monitoring of medication errors.

Evaluation of a remote-controlled laparoscopic camera holder for basic laparoscopic skills acquisition: a randomized controlled trial.

BACKGROUND: Unsteady camera movement and poor visualization contribute to a difficult learning curve for laparoscopic surgery. Remote-controlled camera holders (RCHs) aim to mitigate these factors and may be used to overcome barriers to learning. Our aim was to evaluate performance benefits to laparoscopic skill acquisition in novices using a RCH. METHODS: Novices were randomized into groups using a human camera assistant (HCA) or the FreeHand v1.0 RCH and trained in the (E-BLUS) curriculum. After completing training, a surgical workload questionnaire (SURG-TLX) was issued to participants. RESULTS: Forty volunteers naïve in laparoscopic skill were randomized into control and intervention groups (n = 20) with intention-to-treat analysis. Each participant received up to 10 training sessions using the E-BLUS curriculum. Competency was reached in the peg transfer task in 5.5 and 7.6 sessions for the ACH and HCA groups, respectively (P = 0.015), and 3.6 and 6.8 sessions for the laparoscopic suturing task (P = 0.0004). No significance differences were achieved in the circle cutting (P = 0.18) or needle guidance tasks (P = 0.32). The RCH group experienced significantly lower workload (P = 0.014) due to lower levels of distraction (P = 0.047). CONCLUSIONS: Remote-controlled camera holders have demonstrated the potential to significantly benefit intra-operative performance and surgical experience where camera movement is minimal. Future high-quality studies are needed to evaluate RCHs in clinical practice. TRIAL REGISTRATION: ISRCTN 83733979.

How human activity impacted manufacturing non-compliances: A multivariate analysis in a centralized cytotoxic preparation unit.

INTRODUCTION: The aim of the study was to identify risk factors related to human errors in the preparation of anticancer drugs in order to improve the pharmaceutical process by setting corrective actions. METHOD: Risk factors which could increase the probability of error were identified: daily workload, workload on the previous day and subcontractors' workload, time slot of the preparation, understaffing, incidents which could affect workflow, individual experience of technicians and cleanrooms layout. Drug reconstitution or complex fabrications were also considered as risk factors. We used univariate and multivariate logistic regression analyses to screen for correlation between risks and errors. RESULT: Among 11 278 preparations analyzed, 115 were non-compliant. Univariate analysis shows significant variables: individual experience of technicians, technicians working in the same cleanrooms and technicians' rotations. 2 technicians are significantly associated with a higher risk of error and 5 with a lower risk. The multivariate analysis confirmed the conclusions of the univariate. DISCUSSION: As expected, time slot of the manufacture, cleanrooms layout and some technicians increase the risk of error. Surprisingly, technicians' experience led to increase the risk. This study is a first approach to evaluate the human error aspect in non-compliant preparations, in order to optimize security of antineoplastic drugs preparations.

Frontiers in human factors: embedding specialists in multi-disciplinary efforts to improve healthcare.

Despite the application of a huge range of human factors (HF) principles in a growing range of care contexts, there is much more that could be done to realize this expertise for patient benefit, staff well-being and organizational performance. Healthcare has struggled to embrace system safety approaches, misapplied or misinterpreted others, and has stuck to a range of outdated and potentially counter-productive myths even has safety science has developed. One consequence of these persistent misunderstandings is that few opportunities exist in clinical settings for qualified HF professionals. Instead, HF has been applied by clinicians and others, to highly variable degrees-sometimes great success, but frequently in limited and sometimes counter-productive ways. Meanwhile, HF professionals have struggled to make a meaningful impact on frontline care and have had little career structure or support. However, in the last few years, embedded clinical HF practitioners have begun to have considerable success that are now being supported and amplified by professional networks. The recent coronavirus disease of 2019 (COVID-19) experiences confirm this. Closer collaboration between healthcare and HF professionals will result in significant and ultimately beneficial changes to both professions and clinical care.

Can EEG Be Adopted as a Neuroscience Reference for Assessing Software Programmers' Cognitive Load?

An emergent research area in software engineering and software reliability is the use of wearable biosensors to monitor the cognitive state of software developers during software development tasks. The goal is to gather physiologic manifestations that can be linked to error-prone scenarios related to programmers' cognitive states. In this paper we investigate whether electroencephalography (EEG) can be applied to accurately identify programmers' cognitive load associated with the comprehension of code with different complexity levels. Therefore, a controlled experiment involving 26 programmers was carried. We found that features related to Theta, Alpha, and Beta brain waves have the highest discriminative power, allowing the identification of code lines and demanding higher mental effort. The EEG results reveal evidence of mental effort saturation as code complexity increases. Conversely, the classic software complexity metrics do not accurately represent the mental effort involved in code comprehension. Finally, EEG is proposed as a reference, in particular, the combination of EEG with eye tracking information allows for an accurate identification of code lines that correspond to peaks of cognitive load, providing a reference to help in the future evaluation of the space and time accuracy of programmers' cognitive state monitored using wearable devices compatible with software development activities.

Micro-Behavioral Accidental Click Detection System for Preventing Slip-Based Human Error.

Accidentally clicking on a link is a type of human error known as a slip in which a user unintentionally performs an unintended task. The risk magnitude is the probability of occurrences of such error with a possible substantial effect to which even experienced individuals are susceptible. Phishing attacks take advantage of slip-based human error by attacking psychological aspects of the users that lead to unintentionally clicking on phishing links. Such actions may lead to installing tracking software, downloading malware or viruses, or stealing private, sensitive information, to list a few. Therefore, a system is needed that detects whether a click on a link is intentional or unintentional and, if unintentional, can then prevent it. This paper proposes a micro-behavioral accidental click detection system (ACDS) to prevent slip-based human error. A within-subject-based experiment was conducted with 20 participants to test the potential of the proposed system. The results reveal the statistical significance between the two cases of intentional vs. unintentional clicks using a smartphone. Random tree, random forest, and support vector machine classifiers were used, exhibiting 82.6%, 87.2%, and 91.6% accuracy in detecting unintentional clicks, respectively.