Article
Green & Sustainable Science & Technology
Esra Yalcin, Gokcen Alev Ciftcioglu, Burcin Hulya Guzel
Summary: Organizational and operational human factors have a significant impact on accidents in the chemical industry. Chemical accidents occur in various operations due to multiple factors. Understanding the relationship between these factors and accidents is crucial for preventing recurring accidents and promoting sustainability. This study divided the chemical industry into five operations and used the HFACS method to analyze accident reports. The results showed that high-frequency accidents were caused by organizational processes and skill-based errors in different operations.
Article
Engineering, Industrial
Qiaohong Zheng, Xinwang Liu, Weizhong Wang
Summary: In this study, a consensus model-based risk matrix method is proposed to address the risk analysis of human error factors in medical devices, considering experts' risk acceptability. The Human Factor Analysis and Classification System (HFACS) is integrated with the risk matrix to identify and prioritize human error factors. A novel feedback mechanism and consensus measurement are constructed to guide experts and reach a consensus on risk evaluation information.
RELIABILITY ENGINEERING & SYSTEM SAFETY
(2023)
Article
Computer Science, Artificial Intelligence
Qiaohong Zheng, Xinwang Liu, Weizhong Wang, Qun Wu, Muhammet Deveci, Dragan Pamucar
Summary: This paper proposes an integrated method that combines prospect theory with a consensus model to address the problem of HFACS-based human error factors risk analysis. The integrated method can yield highly acceptable risk analysis results by considering experts' heterogeneous risk preferences.
EXPERT SYSTEMS WITH APPLICATIONS
(2023)
Article
Computer Science, Artificial Intelligence
Qiaohong Zheng, Xinwang Liu, Weizhong Wang, Shilian Han
Summary: Human error factors are a leading cause of medical errors. The HFACS method has been considered valuable for analyzing these factors, but it lacks the ability to handle the interactive relationship among them. This paper proposes an integrated linguistic Z-number-based HFACS framework that captures the uncertainty and reliability of risk evaluation information and the interactive relationships among factors. A case study demonstrates the reliability of the proposed method and emphasizes the importance of considering semantics and interrelationships in risk analysis results.
EXPERT SYSTEMS WITH APPLICATIONS
(2024)
Article
Chemistry, Multidisciplinary
Krzysztof Wrobel, Mateusz Gil, Chong-Ju Chae
Summary: Research and expert analysis have shown that ensuring the safety of remotely-controlled merchant vessels is primarily dependent on addressing known issues promptly, monitoring the psychological and physiological conditions of remote operators, and placing emphasis on the actions of operators as the key barrier against accidents.
APPLIED SCIENCES-BASEL
(2021)
Article
Engineering, Industrial
Cagatay Kandemir, Metin Celik
Summary: The study proposes marine engineering maintenance and operations specific error producing conditions (mmo-EPCs) based on ship accident data, extending the current shipboard operations human reliability analysis (SOHRA). The findings introduce a new method called marine maintenance and operations human reliability analysis (MMOHRA), which significantly alters the values of various error producing conditions compared to similar approaches, demonstrating its potential for improved safety practices in the marine engineering field.
RELIABILITY ENGINEERING & SYSTEM SAFETY
(2021)
Article
Environmental Studies
Ziwei Fa, Xinchun Li, Zunxiang Qiu, Quanlong Liu, Zhengyuan Zhai
Summary: By analyzing a large number of coal mine accident reports, this study established a modified HFACS system and identified strong association rules among various factors. The results indicated that machinery and equipment factors, physical environment factors, and unsafe preconditions directly impact employees' unsafe behaviors, while unsafe supervision is the most influential factor.
Article
Engineering, Chemical
Jingjing Xia, Yi Liu, Dongfeng Zhao, Yue Tian, Jianguo Li, Yufa Zhong, Nitin Roy
Summary: This study conducted a statistical analysis of 120 fatal accidents involving confined space operations in China, summarized the causes and characteristics of these accidents, and established the HFACS-MCS model. Three human influence paths in confined space operations accidents were derived. The results show that inadequate safety culture, organizational process vulnerability, and violations are the principal causes of accidents, with targeted prevention and rescue measures proposed.
JOURNAL OF LOSS PREVENTION IN THE PROCESS INDUSTRIES
(2021)
Article
Engineering, Industrial
Steve J. Bickley, Benno Torgler
Summary: The article proposes a novel adaptation of the Human Factors Analysis and Classification System (HFACS) for proactive incident prevention in public health during the COVID-19 pandemic. By leveraging this approach, targeted measures can be quickly established to mitigate potential errors at different levels within the public health system.
Article
Engineering, Manufacturing
Dini Duan, Zhisheng Zhang, Zhijie Xia
Summary: This study proposes an analytical approach combining Fault Tree Analysis and qualitative analysis to investigate the human factors that cause failures in an organization from the perspective of maintenance personnel. A case study conducted in the Chinese manufacturing industry proves the effectiveness of this approach in understanding the latent factors of maintenance incidents and improving human error analysis.
HUMAN FACTORS AND ERGONOMICS IN MANUFACTURING & SERVICE INDUSTRIES
(2022)
Article
Engineering, Marine
Nermin Hasanspahic, Srdan Vujicic, Vlado Francic, Leo Campara
Summary: By analyzing 135 marine accident reports, the research revealed that the causes of marine accidents primarily depend on two human factor categories. By influencing these factors, the number of accidents could be reduced and shipping safety improved in general.
JOURNAL OF MARINE SCIENCE AND ENGINEERING
(2021)
Article
Engineering, Industrial
Chia-Fen Chi, Davin Sigmund, Yu-Chieh Lin, Colin G. Drury
Summary: The current study analyzed the root causes of 22 helicopter accidents/incidents that occurred between 1998 and 2019. A new classification scheme was proposed to better identify recurring factors and guide future prevention strategies.
APPLIED ERGONOMICS
(2022)
Review
Engineering, Industrial
Mona Ahmadi Rad, Lianne M. Lefsrud, Michael T. Hendry
Summary: Accident analysis methods are used to identify the factors and processes leading to an accident. This paper fills the research gap in systemic accident modelling in railways through a literature review and bibliometric analysis. The study identifies the popularity of HFACS, STAMP, and FRAM in railway accident studies, and highlights the need for qualitative and quantitative improvements of the methods.
Article
Ergonomics
Yibing Wu, Shuguang Zhang, Xuan Zhang, Yi Lu, Zhiyue Xiong
Summary: Human factors are the leading cause of aircraft accidents, and this paper proposes a hybrid HFACS-SD model to reveal the risk evolution mechanism of aviation human factors. The simulation results show that the proposed model can replicate the evolution trend of accident rate and identify critical loops and parameters.
ACCIDENT ANALYSIS AND PREVENTION
(2023)
Article
Engineering, Marine
Laihao Ma, Xiaoxue Ma, He Lan, Yang Liu, Wanyi Deng
Summary: A data-driven method is proposed to measure the interrelations between human factors contributing to maritime accidents. The method integrates HFACS, DEMATEL, and FCM to analyze ship collision accident reports, identify human factors, and determine their causal relationships and importance ranking. The results provide objective and realistic insights into the important human factors and their impact in maritime accidents.
Review
Health Care Sciences & Services
Douglas A. Wiegmann, Laura J. Wood, Tara N. Cohen, Scott A. Shappell
Summary: This article reviews the Theory of Active and Latent Failures, also known as the Swiss cheese model, and aims to provide a better understanding of its underlying theory. The goal is to help patient safety professionals leverage the model and its tools for root cause analysis and other patient safety activities.
JOURNAL OF PATIENT SAFETY
(2022)
Review
Engineering, Industrial
Tara N. Cohen, Douglas A. Wiegmann, Falisha F. Kanji, Myrtede Alfred, Jennifer T. Anger, Ken R. Catchpole
Summary: This systematic review provides information on methodologies, measurements and classification systems used in observational studies of flow disruptions in clinical environments, analyzing 30 studies and synthesizing the findings into a framework for conducting rigorous methodological studies aimed at understanding clinical systems.
APPLIED ERGONOMICS
(2022)
Article
Obstetrics & Gynecology
Tara N. Cohen, Falisha F. Kanji, Colby Souders, Alexandra Dubinskaya, Karyn S. Eilber, Harry Sax, Jennifer T. Anger
Summary: This study applied a structured human factors analysis to identify conditions contributing to vaginal retained foreign objects (RFOs). The most common items were vaginal packing and vaginal sponges. The main contributing factors were skill-based errors and communication breakdowns. Human factors interventions, such as simulation, teamwork training, and streamlining workflow, can address and improve these errors.
JOURNAL OF MINIMALLY INVASIVE GYNECOLOGY
(2022)
Letter
Surgery
Ken Catchpole, Connor Lusk, Matthias Weigl, Jennifer Anger, Tara Cohen
Summary: This letter to the editor responds to the concept of flow disruptions in robot-assisted surgery studies, clarifying misconceptions and emphasizing the importance of understanding the clinical process from a systems perspective.
JOURNAL OF ROBOTIC SURGERY
(2022)
Article
Behavioral Sciences
Ken Catchpole, Tara Cohen, Myrtede Alfred, Sam Lawton, Falisha Kanji, Daniel Shouhed, Lynne Nemeth, Jennifer Anger
Summary: Using the example of robotic-assisted surgery, this study explores the challenges of technology integration in surgery and emphasizes the importance of systems engineering and clinical human factors research. Human factors studies of robotic surgery have provided insights into hidden complexities and suggested methods for improvement. There is a growing need for human-systems integration to enhance safety and quality in healthcare.
Article
Surgery
Tara N. Cohen, Jennifer T. Anger, Kevin Shamash, Kenneth R. Catchpole, Raymund Avenido, Eric J. Ley, Bruce L. Gewertz, Daniel Shouhed
Summary: This study applied a human factors approach to reduce turnover time in robotic surgery. Through observation and analysis of 40 robotic surgery turnovers, researchers developed targeted interventions. Post-intervention, turnover time was significantly reduced by 26 minutes and major delays decreased by over 50%.
WORLD JOURNAL OF SURGERY
(2022)
Article
Health Care Sciences & Services
Tara N. Cohen, Jennifer T. Anger, Falisha F. Kanji, Jennifer Zamudio, Elise DeForest, Connor Lusk, Ray Avenido, Christine Yoshizawa, Stephanie Bartkowicz, Lynne S. Nemeth, Ken Catchpole
Summary: The RAS Olympics was successfully implemented as a game-based educational competition to improve skills in robotic-assisted surgery. Participants positively responded to the activity, finding it relevant to their work and effective in learning new techniques to enhance their practice. The interactive learning environment of the RAS Olympics was preferred over traditional training methods.
JOURNAL OF PATIENT SAFETY
(2022)
Article
Health Care Sciences & Services
Myrtede Alfred, John Del Gaizo, Falisha Kanji, Samuel Lawton, Ashley Caron, Lynne S. Nemeth, A. Alekseyenko, Daniel Shouhed, Stephen Savage, Jennifer T. Anger, Ken Catchpole, Tara Cohen
Summary: Direct observation is valuable for identifying latent threats and system complexity in clinical environments. Effective and comprehensive observer training is critical for ensuring reliability and reproducibility of data collection. However, ensuring methodological rigour remains a challenge in direct observation research in healthcare.
BMJ QUALITY & SAFETY
(2022)
Article
Education & Educational Research
Shawn M. Doherty, Andrew C. Griggs, Elizabeth H. Lazzara, Joseph R. Keebler, Bruce L. Gewertz, Tara N. Cohen
Summary: The purpose of this article is to provide seven considerations that are relevant to the development, implementation, and effectiveness of an escape room. These considerations include determining the objectives, identifying a theme, assigning the roles, establishing participant interdependence, selecting a venue, designing the puzzles, and creating the assessments. These considerations can advance the science underlying the use of escape rooms and preclude difficulties associated with their use.
SIMULATION & GAMING
(2023)
Review
Surgery
Tara N. Cohen, Falisha F. Kanji, Andrew S. Wang, Edward G. Seferian, Harry C. Sax, Bruce L. Gewertz
Summary: This study reviewed the demographics of intraoperative deaths (ID) and found that most deaths occurred during emergency procedures. However, the incident reports provided little actionable information on ergonomic factors.
AMERICAN JOURNAL OF SURGERY
(2023)
Article
Surgery
Jennifer Zamudio, Jeffrey Woodward, Falisha F. Kanji, Jennifer T. Anger, Ken Catchpole, Tara N. Cohen
Summary: This study assessed workload in robotic-assisted surgery by administering SURG-TLX surveys to surgical staff at three sites. The results showed significantly higher workload during urology and gynecology procedures, and significant differences in domain workload by role and specialty, highlighting the need for tailored workload interventions.
AMERICAN JOURNAL OF SURGERY
(2023)
Article
Surgery
Jennifer Zamudio, Falisha F. Kanji, Connor Lusk, Daniel Shouhed, Barry R. Sanchez, Ken Catchpole, Jennifer T. Anger, Tara N. Cohen
Summary: Robotic bariatric surgery is an effective treatment for extreme obesity, but it presents challenges for OR teams and the clinical system. This study found that flow disruptions were most frequent during patient transfer and robot docking phases of RBS, with coordination issues being the main contributing factor.
Review
Urology & Nephrology
Alexandra Dubinskaya, John R. Heard, Eunice Choi, Tara Cohen, Jennifer Anger, Karyn Eilber, Victoria Scott
Summary: This study aimed to evaluate the educational content and services of existing applications on female sexual health. A total of 17 apps were identified and reviewed, covering different themes such as education, emotions and communication, relaxation and meditation, general sexual health, and social and fun. The study demonstrated the need for more accessible educational resources addressing female sexual health and dysfunction.
SEXUAL MEDICINE REVIEWS
(2023)
Article
Medicine, Research & Experimental
Carl T. Berdahl, Andrew J. Henreid, Tara N. Cohen, Bernice L. Coleman, Edward G. Seferian, Donna Leang, Sungjin Kim, Marcio A. Diniz, Matthew Grissinger, Karen Kaiser, Sara McCleskey, Xi Zhu, Teryl K. Nuckols
Summary: This study aims to improve hospital incident reporting systems and enhance patient safety by implementing the Safety Action Feedback and Engagement (SAFE) Loop. The SAFE Loop incorporates various strategies such as prioritizing safety issues, training nurses to write informative reports, and providing feedback to nurses. The study will be conducted in 20 nursing units at a hospital in Los Angeles, and outcomes will include incident reporting practices, nurses' attitudes, and rates of high-priority events.
CONTEMPORARY CLINICAL TRIALS COMMUNICATIONS
(2023)
Meeting Abstract
Medicine, Research & Experimental
Kenechukwu Ojukwu, Michael Kozak, Chau Bui, Tiffany Lee, Stephanie Dreikorn, David Afework, Bonnie Balzer, Farin Amersi, Tara Cohen, Monica Jain, Kevin Waters
LABORATORY INVESTIGATION
(2023)
