14 research outputs found

    Resilience Engineering in Practice

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    A simulation framework for mapping risks in clinical processes: the case of in-patient transfers

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    Objective: To model how individual violations in routine clinical processes cumulatively contribute to the risk of adverse events in hospital using an agent-based simulation framework. Design: An agent-based simulation was designed to model the cascade of common violations that contribute to the risk of adverse events in routine clinical processes. Clinicians and the information systems that support them were represented as a group of interacting agents using data from direct observations. The model was calibrated using data from 101 patient transfers observed in a hospital and results were validated for one of two scenarios (a misidentification scenario and an infection control scenario). Repeated simulations using the calibrated model were undertaken to create a distribution of possible process outcomes. The likelihood of end-of-chain risk is the main outcome measure, reported for each of the two scenarios. Results: The simulations demonstrate end-of-chain risks of 8% and 24% for the misidentification and infection control scenarios, respectively. Over 95% of the simulations in both scenarios are unique, indicating that the in-patient transfer process diverges from prescribed work practices in a variety of ways. Conclusions: The simulation allowed us to model the risk of adverse events in a clinical process, by generating the variety of possible work subject to violations, a novel prospective risk analysis method. The in-patient transfer process has a high proportion of unique trajectories, implying that risk mitigation may benefit from focusing on reducing complexity rather than augmenting the process with further rule-based protocols.8 page(s

    Resilience engineering in practice: A Guidebook

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    Resilience engineering has since 2004 attracted widespread interest from industry as well as academia. Practitioners from various fields, such as aviation and air traffic management, patient safety, off-shore exploration and production, have quickly realised the potential of resilience engineering and have became early adopters. The continued development of resilience engineering has focused on four abilities that are essential for resilience. These are the ability a) to respond to what happens, b) to monitor critical developments, c) to anticipate future threats and opportunities, and d) to learn from past experience - successes as well as failures. Working with the four abilities provides a structured way of analysing problems and issues, as well as of proposing practical solutions (concepts, tools, and methods). This book is divided into four main sections which describe issues relating to each of the four abilities. The chapters in each section emphasise practical ways of engineering resilience and feature case studies and real applications. The text is written to be easily accessible for readers who are more interested in solutions than in research, but will also be of interest to the latter group

    A Description of the Revised ATHEANA (A Technique for Human Event Analysis)

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    This paper describes the most recent version of a human reliability analysis (HRA) method called ``A Technique for Human Event Analysis'' (ATHEANA). The new version is documented in NUREG-1624, Rev. 1 [1] and reflects improvements to the method based on comments received from a peer review that was held in 1998 (see [2] for a detailed discussion of the peer review comments) and on the results of an initial trial application of the method conducted at a nuclear power plant in 1997 (see Appendix A in [3]). A summary of the more important recommendations resulting from the peer review and trial application is provided and critical and unique aspects of the revised method are discussed

    Discussion of Comments from a Peer Review of A Technique for Human Event Anlysis (ATHEANA)

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    In May of 1998, a technical basis and implementation guidelines document for A Technique for Human Event Analysis (ATHEANA) was issued as a draft report for public comment (NUREG-1624). In conjunction with the release of draft NUREG- 1624, a peer review of the new human reliability analysis method its documentation and the results of an initial test of the method was held over a two-day period in June 1998 in Seattle, Washington. Four internationally known and respected experts in HK4 or probabilistic risk assessment were selected to serve as the peer reviewers. In addition, approximately 20 other individuals with an interest in HRA and ATHEANA also attended the peer and were invited to provide comments. The peer review team was asked to comment on any aspect of the method or the report in which improvements could be made and to discuss its strengths and weaknesses. They were asked to focus on two major aspects: Are the basic premises of ATHEANA on solid ground and is the conceptual basis adequate? Is the ATHEANA implementation process adequate given the description of the intended users in the documentation? The four peer reviewers asked questions and provided oral comments during the peer review meeting and provided written comments approximately two weeks after the completion of the meeting. This paper discusses their major comments

    Evaluation of Human Performance Issues for Fire Risk

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    This paper summarizes the current status of the treatment of human reliability in fire risk analyses for nuclear power plants and identifies areas that need to be addressed. A new approach is suggested to improve the modeling

    Trial application of a technique for human error analysis (ATHEANA)

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    The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context

    A process for application of ATHEANA - a new HRA method

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    This paper describes the analytical process for the application of ATHEANA, a new approach to the performance of human reliability analysis as part of a PRA. This new method, unlike existing methods, is based upon an understanding of the reasons why people make errors, and was developed primarily to address the analysis of errors of commission

    Knowledge-base for the new human reliability analysis method, A Technique for Human Error Analysis (ATHEANA)

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    This paper describes the knowledge base for the application of the new human reliability analysis (HRA) method, a ``A Technique for Human Error Analysis`` (ATHEANA). Since application of ATHEANA requires the identification of previously unmodeled human failure events, especially errors of commission, and associated error-forcing contexts (i.e., combinations of plant conditions and performance shaping factors), this knowledge base is an essential aid for the HRA analyst
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