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Human factors error

Marina Englert, Glaucya Madazio, Ingrid Gielow, Jorge Lucero, Mara Behlau
PURPOSE: To investigate the learning factor during a perceptual-auditory analysis of an unusual task in three different groups. METHODS: 269 listeners, divided into three groups: 73 voice specialists Speech Language Pathologists (EG), 84 voice specialists Speech Language Pathologists (NEG); and 112 non-speech pathologists in the Naive Group (NG). They all completed a listening session that included 18 synthesized and 18 human voices with different types and degrees of deviation (50% of repetition for intra-rater consistency analysis)...
June 7, 2018: CoDAS
Sarah L Krein, Jeanmarie Mayer, Molly Harrod, Lauren E Weston, Lynn Gregory, Laura Petersen, Matthew H Samore, Frank A Drews
Importance: Using personal protective equipment (PPE) and transmission-based precautions are primary strategies for reducing the transmission of infectious agents. Objective: To identify and characterize failures in transmission-based precautions, including PPE use, by health care personnel that could result in self-contamination or transmission during routine, everyday hospital care. Design, Setting, and Participants: This qualitative study involved direct observation inside and outside patient rooms on clinical units from March 1, 2016, to November 30, 2016...
June 11, 2018: JAMA Internal Medicine
Vishwesh Nath, Kurt G Schilling, Allison E Hainline, Prasanna Parvathaneni, Justin A Blaber, Ilwoo Lyu, Adam W Anderson, Hakmook Kang, Allen T Newton, Baxter P Rogers, Bennett A Landman
High Angular Resolution Diffusion Imaging (HARDI) models are used to capture complex intra-voxel microarchitectures. The magnetic resonance imaging sequences that are sensitized to diffusion are often highly accelerated and prone to motion, physiologic, and imaging artifacts. In diffusion tensor imaging, robust statistical approaches have been shown to greatly reduce these adverse factors without human intervention. Similar approaches would be possible with HARDI methods, but robust versions of each distinct HARDI approach would be necessary...
March 2018: Proceedings of SPIE
Aneurin Canham, Gyuchan Thomas Jun, Patrick Waterson, Suzanne Khalid
There is growing awareness of the limitations of current practice regarding the investigation of patient safety incidents, including a reliance on Root Cause Analysis (RCA) and a lack of safety expertise. Human Factors and Ergonomics (HFE) can offer safety expertise and systemic approaches to incident analysis. However, HFE is underutilised in healthcare. This study aims to explore the integration of HFE systemic accident analysis into current practice. The study compares the processes and outputs of a current practice RCA-based incident analysis and a Systems Theoretic Accident Modelling and Processes (STAMP) analysis on the same medication error incident...
October 2018: Applied Ergonomics
Jane Ferguson, Liz Seston, Darren M Ashcroft
BACKGROUND: Transition between care settings is a time of high risk for preventable medication errors. Poor communication about medication changes on discharge from hospital can result in adverse drug events and medicines-related readmissions. Refer-to-Pharmacy is a novel electronic referral system that allows hospital pharmacy staff to refer patients from their bedside to their community pharmacist for post-hospital discharge medication support. The aim of this study was to examine factors that promoted or inhibited the implementation of Refer-to-Pharmacy in hospital and community settings...
June 7, 2018: BMC Health Services Research
Diane M Rudolphi, Jessica Madiraca, Erlinda C Wheeler
The aim of this study was to identify medical-surgical clinical error near-miss events (ENME) and causative factors as reported by senior-level nursing students. Qualitative and quantitative ENME data were obtained using a survey tool during clinical courses. Students identified cognitive and behavioral/performance issues, human factors, system issues, and communication as contributing factors, with 97 percent of the errors reported as preventable. Identifying ENMEs with causative factors may ultimately increase patient safety...
June 6, 2018: Nursing Education Perspectives
Shelly Lachish, Kris A Murray
Wildlife diseases have important implications for wildlife and human health, the preservation of biodiversity and the resilience of ecosystems. However, understanding disease dynamics and the impacts of pathogens in wild populations is challenging because these complex systems can rarely, if ever, be observed without error. Uncertainty in disease ecology studies is commonly defined in terms of either heterogeneity in detectability (due to variation in the probability of encountering, capturing, or detecting individuals in their natural habitat) or uncertainty in disease state assignment (due to misclassification errors or incomplete information)...
2018: Frontiers in Veterinary Science
Aisha Souquette, Paul G Thomas
Influenza virus frequently mutates due to its error-prone polymerase. This feature contributes to influenza virus's ability to evade pre-existing immunity, leading to annual epidemics and periodic pandemics. T cell memory plays a key protective role in the face of an antigenically distinct influenza virus strain because T cell targets are often derived from conserved internal proteins, whereas humoral immunity targets are often sites of increased mutation rates that are tolerated by the virus. Most studies of influenza T cell memory are conducted in naive, specific pathogen free mice and do not account for repetitive influenza infection throughout a lifetime, sequential acute heterologous infections between influenza infections, or heterologous chronic co-infections...
2018: Frontiers in Immunology
Matthias Münzberg, Miriam Rüsseler, Martin Egerth, Anna Katharina Doepfer, Manuel Mutschler, Richard Stange, Bertil Bouillon, Bernd Kladny, Reinhard Hoffmann
INTRODUCTION: The development of a new safety culture in orthopaedics and trauma surgery needs to be based on the knowledge of the status quo. The objective of this research was therefore to perform a survey of orthopaedic and trauma surgeons to achieve a subjective assessment of the frequency and causes of "insecurities" or errors in daily practice. METHODS: Based on current literature, an online questionnaire was created by a team of experts (26 questions total) and was sent via e-mail to all active members of a medical society (DGOU) in April 2015...
June 5, 2018: Zeitschrift Für Orthopädie und Unfallchirurgie
Thomas Ly, Carol Pamer, Oanh Dang, Sonja Brajovic, Shahrukh Haider, Taxiarchis Botsis, David Milward, Andrew Winter, Susan Lu, Robert Ball
INTRODUCTION: The FDA Adverse Event Reporting System (FAERS) is a primary data source for identifying unlabeled adverse events (AEs) in a drug or biologic drug product's postmarketing phase. Many AE reports must be reviewed by drug safety experts to identify unlabeled AEs, even if the reported AEs are previously identified, labeled AEs. Integrating the labeling status of drug product AEs into FAERS could increase report triage and review efficiency. Medical Dictionary for Regulatory Activities (MedDRA) is the standard for coding AE terms in FAERS cases...
May 31, 2018: Journal of Biomedical Informatics
Lachlan Munn, Carl N Stephan
Soft tissues of the human face hang from the skull under the downward vector of gravity. Subsequently, the fall of the tissues is not likely the same between supine, prone or upright positions with ramifications for soft tissue measurements such as average soft tissue thicknesses used in craniofacial identification. Here we use high-resolution Dimensional Imaging® DI3D stereo-photographs (Glasgow, Scotland) to map the shape change between upright and supine position in the same 62 participants and encode the surface shell differences as greyscale pixel intensity values...
May 17, 2018: Forensic Science International
Jessica A Wignall, Eugene Muratov, Alexander Sedykh, Kathryn Z Guyton, Alexander Tropsha, Ivan Rusyn, Weihsueh A Chiu
BACKGROUND: Human health assessments synthesize human, animal, and mechanistic data to produce toxicity values that are key inputs to risk-based decision making. Traditional assessments are data-, time-, and resource-intensive, and they cannot be developed for most environmental chemicals owing to a lack of appropriate data. OBJECTIVES: As recommended by the National Research Council, we propose a solution for predicting toxicity values for data-poor chemicals through development of quantitative structure-activity relationship (QSAR) models...
May 2018: Environmental Health Perspectives
Jesse T Jacob, Loreen A Herwaldt, Francis T Durso
PURPOSE OF REVIEW: Human factors engineering (HFE) approaches are increasingly being used in healthcare, but have been applied in relatively limited ways to infection prevention and control (IPC). Previous studies have focused on using selected HFE tools, but newer literature supports a system-based HFE approach to IPC. RECENT FINDINGS: Cross-contamination and the existence of workarounds suggest that healthcare workers need better support to reduce and simplify steps in delivering care...
May 24, 2018: Current Opinion in Infectious Diseases
Scott A Read, Emily C Pieterse, David Alonso-Caneiro, Rebekah Bormann, Seentinie Hong, Chai-Hoon Lo, Rhiannon Richer, Atif Syed, Linda Tran
Ambient light exposure is one environmental factor thought to play a role in the regulation of eye growth and refractive error development, and choroidal thickness changes have also been linked to longer term changes in eye growth. Therefore in this study we aimed to examine the influence of a 1-week period of morning light therapy upon choroidal thickness. Twenty two healthy young adult subjects had a series of macular choroidal thickness measurements collected with spectral domain optical coherence tomography before, and then following a 7-day period of increased daily light exposure...
May 29, 2018: Scientific Reports
Tadashi Kamio, Ken Masamune
BACKGROUND: Although the ICU is the most appropriate place to care for mechanically ventilated patients, a considerable number are ventilated in general medical care wards all over the world. However, adverse events focusing on mechanically ventilated patients in general care have not been explored. METHODS: Data from the Japan Council for Quality Health Care database were analyzed. Patient safety incidents from January 2010 to November 2017 regarding mechanical ventilation were collected, and comparisons of patient safety incidents between ICUs/high care units (HCUs) and general care wards were made...
May 29, 2018: Respiratory Care
K Lange, A Brinker, M Nowak, C Zöllner, W Lauer
BACKGROUND: The Federal Institute for Drugs and Medical Devices (BfArM) was notified of an event in which it was not possible to sufficiently ventilate a patient suffering a severe asthma attack. It turned out that the ventilation pressures used by the device for pressure-controlled ventilation were below the values set by the user, which the user was not aware of. The ventilation pressures chosen by the user exceeded the preset alarm limits of the ventilator. This pressure and alarm management significantly differed from that of other ventilators used in the hospital...
May 25, 2018: Der Anaesthesist
Hajime Utsuno, Toru Kageyama, Keiicchi Uchida, Namiko Ishii, Saki Minegishi, Koichi Uemura, Koichi Sakurada
Forensic facial approximation is a technique used to estimate the antemortem facial features of unknown skeletal remains. In recent years, many researchers have reported nasal tip predictions with positive results. However, the morphological nasal features of the skull can vary widely, and it is hard to obtain accurate values using facial approximation techniques. We assumed that these variations are due to an over-dependence on the values obtained from a single distance metric factor in an anatomical area...
May 4, 2018: Forensic Science International
Andy Stock, Larry B Crowder, Benjamin S Halpern, Fiorenza Micheli
Increasing anthropogenic pressure on marine ecosystems from fishing, pollution, climate change and other sources is a big concern in marine conservation. Scientists have thus developed spatial models to map cumulative human impacts on marine ecosystems. However, these models make many assumptions and incorporate data that suffer from substantial incompleteness and inaccuracies. Here, as opposed to using a single model, we used Monte Carlo simulations to identify which parts of the oceans are most and least impacted by anthropogenic stressors under seven simulated sources of uncertainty (factors), including errors in the input data and choices between alternative model assumptions...
May 24, 2018: Conservation Biology: the Journal of the Society for Conservation Biology
W Holmes Finch, Sungok Serena Shim
Collection and analysis of longitudinal data is an important tool in understanding growth and development over time in a whole range of human endeavors. Ideally, researchers working in the longitudinal framework are able to collect data at more than two points in time, as this will provide them with the potential for a deeper understanding of the development processes under study and a much broader array of statistical modeling options. However, in some circumstances data collection is limited to only two time points, perhaps because of resource limitations, issues with the context in which the data are collected, or the nature of the trait under study...
April 2018: Educational and Psychological Measurement
Daniel R Cavagnaro, Clintin P Davis-Stober
Within modern psychology, computational and statistical models play an important role in describing a wide variety of human behavior. Model selection analyses are typically used to classify individuals according to the model(s) that best describe their behavior. These classifications are inherently probabilistic, which presents challenges for performing group-level analyses, such as quantifying the effect of an experimental manipulation. We answer this challenge by presenting a method for quantifying treatment effects in terms of distributional changes in model-based (i...
May 21, 2018: Psychological Methods
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