Transfusion adverse events in a tertiary hospital from 2016 to 2022: a retrospective analysis / 中国输血杂志

【Objective】 To strengthen the management of transfusion adverse events, so as to reduce the occurrence of medical damage and accidents, and guarantee the safety of blood transfusion. 【Methods】 The adverse events of blood transfusion reported in our hospital from July 2016 to December 2022 were collected, the reasons were tracked, and continuous improvements were made. 【Results】 From 2016 to 2022, a total of 315 transfusion adverse events were reported, including 233(73.97%, 233/315) cases of transfusion reactions and 82(26.03%, 82/315) transfusion adverse events. There were 271 328 transfusion cases in the same period, and the incidence of transfusion reactions was 0.858 7‰(233/271 328). The number of transfusion application was 129 887, and the incidence of transfusion adverse event is 0.631 3‰(82/129 887). Sixty-eigtht(82.93%, 68/82) cases of transfusion adverse events were caused by human factors, while the other 14(17.07%, 14/82) cases were non-human factors. According to the linear regression analysis, we have concluded that the year is a significant indicator for transfusion reaction rates (P0.05). 【Conclusion】 Strengthening the management of reporting adverse events in clinical blood transfusion, monitoring the incidence, analyzing and improving different types of adverse events by management tools can reduce the medical risks of blood transfusion and help to guarantee the safety of clinical blood transfusion.

Procedimiento para el análisis y la prevención de errores de medicación usando el enfoque de la ergonomía

Los errores de medicación representan un problema de salud pública que afecta la seguridad del paciente y la calidad de los servicios de salud a escala global. En este artículo se presenta un procedimiento para el análisis y la prevención de los errores de medicación desde la perspectiva de la ergonomía, ejemplificándose su aplicación mediante un caso de estudio ilustrativo de administración de un medicamento inyectable. Como parte del procedimiento expuesto, se incluyeron los reconocidos métodos Hierarchical Task Analysis (HTA) para el análisis de la tarea y Systematic Human Error Reduction and Prediction Approach (SHERPA) para la identificación de los modos de error. Para la valoración de riegos se empleó la matriz de riesgos propuesta en la norma ISO 45001. El procedimiento propuesto quedó conformado por cuatro etapas: 1) selección de la tarea objeto de estudio, 2) análisis detallado de la tarea, 3) predicción de la posibilidad de error y 4) desarrollo de estrategias para la reducción del error. Se espera que la utilización sistemática de este procedimiento contribuya en la mejora de la calidad de los servicios de salud, disminuyendo los errores humanos y los posibles eventos adversos.

Medication errors represent a public health problem that affects patient safety and the quality of healthcare services globally. This article presents a procedure for the analysis and prevention of medication errors from the perspective of ergonomics, exemplifying its application through a case study. The well-known Hierarchical Task Analysis (HTA) and the Systematic Human Error Reduction and Prediction Approach (SHERPA) methods are included. The risk assessment was based on the risk matrix proposed in the ISO 45001 standard. The proposed procedure is structured in four stages: 1) selection of the task to be analysed, 2) detailed analysis of the task, 3) prediction of the possibility of error, 4) error reduction strategies. The use of the procedure is exemplified through a case study of the administration of an injectable drug. The systematic use of this procedure is expected to contribute to the improvement of the quality of health services by reducing human errors and possible adverse events.

Os erros de medicação representam um problema de saúde pública que afeta a segurança do paciente e a qualidade dos serviços de saúde em escala global. Este artigo apresenta um procedimento para a análise e prevenção de erros de medicação do ponto de vista ergonômico, exemplificado por um estudo de caso. Foram incluídos os métodos reconhecidos de Análise Hierárquica de Tarefas (HTA) para análise de tarefas e a Abordagem Sistemática de Redução e Previsão de Erros Humanos (SHERPA) para identificação de modos de erro. A avaliação do risco baseou-se na matriz de risco proposta na norma ISO 45001. O procedimento proposto é composto de quatro etapas: 1) seleção da tarefa em estudo, 2) análise detalhada da tarefa, 3) previsão da possibilidade de erro, 4) estratégias de redução de erros. A aplicação do procedimento é ilustrada por um estudo de caso de administração de um medicamento injetável. Espera-se que o uso sistemático deste procedimento contribua para a melhoria da qualidade dos serviços de saúde, reduzindo erros humanos e possíveis eventos adversos.

Un modelo para la evaluación de las habilidades no técnicas en anestesiología: una revisión de la literatura / A model for the assessment of non-technical skills in anesthesiology: a literature review

Resumen: Hasta 80% de los errores médicos se deben a fallas en factores humanos (mala comunicación, monitoreo inadecuado, fallas de verificación, etc.), por lo que el entrenamiento de los anestesiólogos exige el desarrollo de habilidades no técnicas en anestesiología. Las habilidades no técnicas son las habilidades cognitivas, sociales y personales que complementan las habilidades técnicas, y que contribuyen al desempeño seguro y eficiente de la tarea. En 2004 la Universidad de Aberdeen fue la primera en plantear un modelo para la definición y evaluación de estas habilidades en el ámbito médico. El modelo práctico consta de 15 elementos incluidos en cuatro categorías: manejo de la tarea, trabajo en equipo, conciencia de la situación y toma de decisiones. La herramienta es utilizada por anestesiólogos graduados para evaluar a quienes están en entrenamiento en el quirófano o mediante simulación clínica. La validez de este sistema, así como su importancia en la seguridad del paciente, ha sido demostrada por diferentes estudios.

Abstract: Close to 80% of medical errors are due to human factors (poor communication, inadequate monitoring, failure to check, etc.), which is why training for anaesthetists requires developing essential soft skills for Anaesthesiology. Soft skills are defined as specific cognitive, socio-emotional and interpersonal abilities complementing core skills which contribute to the safe and efficient carrying out of a job-specific task. In 2004, the University of Aberdeen established a first model for defining and evaluating these soft skills. The model consists of 15 elements across four categories: task management, team working, situational awareness and decision-making. The model is a tool employed by postgraduate anaesthesiologists to assess trainees in the operating theatre or through clinical simulation. The validity of this system, as well as its importance for patient safety have been demonstrated in a range of studies.

Practice of Human Factors Training Based on SHEL Model:Patient Safety Education for First Year Medical Students / 医学教育

Introduction: The theory of Human Factors (HF), which designs work and environment according to human characteristics, contributes to patient safety. However, there are not enough reports of systematic educational practices on HF. Our training was designed and practiced using SHEL, an explanatory model of HF.　Methods: Ten training sessions were conducted on the components of SHEL, including Software: manual design, Hardware: user-friendly medical device design, Environment: work environment design, Liveware (self) : human characteristics, and Liveware (others) : teamwork.　Reflection: The HF training using SHEL may lead to acquiring procedural knowledge of patient safety management, and to better understanding of HF by students. In addition, focusing on daily errors is expected to increase students’ learning motivation.

Surgimiento y evolución de la ergonomía como disciplina: reflexiones sobre la escuela de los factores humanos y la escuela de la ergonomía de la actividad / Emergence and evolution of ergonomics as a discipline: reflections on the school of human factors and the school of ergonomics of the activity / Surgimento e evolução da ergonomia como disciplina: reflexões sobre a escola dos fatores humanos e a escola de ergonomia da atividade

Resumen La ergonomía es considerada, en la actualidad, una disciplina científica consolidada, que se expande continuamente a nivel global. Este escenario actual es el resultado de diferentes visiones que han permeado la evolución de la ergonomía. En este artículo se hace un recorrido histórico de la ergonomía como disciplina, tomando en cuenta la escuela de los factores humanos y la escuela de la ergonomía de la actividad. Se presentan los orígenes de estas escuelas, sus paradigmas subyacentes y se realiza una comparación entre ellas. Las reflexiones presentadas en el artículo en torno a la ergonomía parten de la idea que, desde las diferencias y la diversidad, se erige el desarrollo. Los autores de este artículo son partidarios de abordar la ergonomía como una única disciplina, reconociendo la convergencia y la complementariedad entre las dos escuelas. Más allá de las diferencias existentes, la práctica de la ergonomía debe enfocarse en el diseño de los sistemas de trabajo, tomando como eje central al ser humano. Se espera que estas reflexiones permitan a los profesionales de la ergonomía y de otras diciplinas afines ganar mayor comprensión de cómo abordar la actividad humana para transformarla positivamente.

Abstract Ergonomics is now considered a consolidated scientific discipline that is continually expanding globally. This current scenario is the result of different visions that have permeated the evolution of ergonomics. This article presents a historical overview of ergonomics as a discipline considering human factors and the activity-oriented ergonomics schools. The origins of these two schools of thought on ergonomics and their underlying paradigms are presented, and a comparison between them is made. The reflections presented in the article on ergonomics are based on the idea that progress is built on differences and diversity. The authors of this article support the idea of approaching ergonomics as a single discipline, recognizing the convergence and complementarity between the two schools. Beyond the existing differences, ergonomics' practice should be focused on the design of human-centered work systems. It is hoped that the reflections made in this article will enable professionals in ergonomics and other related disciplines to understand how to approach human at work to transform working conditions positively.

Resumo A ergonomia é considerada, na atualidade, uma disciplina científica consolidada, que se expande continuamente a nível global. Este cenário atual es el resultado de diferentes visões que han permeado la evolución de la ergonomía. Neste artigo se tem uma recorrido histórico da ergonomia como disciplina, tomando na cuenta a escola dos fatores humanos e a escola da ergonomia da atividade. Se presentan los orígenes de estas escuelas, sus paradigmas subyacentes y se una realiza comparación entre ellas. Las reflexiones presentadas en el artículo en torno a la ergonomía parten de la idea that, from las diferencias y la diversidad, se erige el desarrollo. Los autores de este artículo son partidarios de abordar la ergonomía como una única disciplina, reconociendo la convergencia y la complementariedad entre las dos escuelas. Más allá de las diferencias existentes, la práctica de la ergonomía debe enfocarse en el diseño de los sistemas de trabajo, tomando como eje central al ser humano. Se espera que estas reflexiones permitan a los profesionales de la ergonomía y de otras diciplinas afines ganar mayor comprensión de cómo abordar la actividad humana para transformarla positivamente.

Human factors engineering of brain-computer interface and its applications: Human-centered brain-computer interface design and evaluation methodology / 生物医学工程学杂志

Brain-computer interface (BCI) is a revolutionizing human-computer Interaction, which is developing towards the direction of intelligent brain-computer interaction and brain-computer intelligent integration. However, the practical application of BCI is facing great challenges. The maturity of BCI technology has not yet reached the needs of users. The traditional design method of BCI needs to be improved. It is necessary to pay attention to BCI human factors engineering, which plays an important role in narrowing the gap between research and practical application, but it has not attracted enough attention and has not been specifically discussed in depth. Aiming at BCI human factors engineering, this article expounds the design requirements (from users), design ideas, objectives and methods, as well as evaluation indexes of BCI with the human-centred-design. BCI human factors engineering is expected to make BCI system design under different use conditions more in line with human characteristics, abilities and needs, improve the user satisfaction of BCI system, enhance the user experience of BCI system, improve the intelligence of BCI, and make BCI move towards practical application.

Human Factors Analysis Of Online Learning Process For Students On Selected Indonesian Campus (A Preliminary Study)

@#The fourth industrial revolution is impacting the learning industry to become online learning, especially in Indonesia. Online learning provides benefits in that it can be cheaper, takes less time, can be self-paced, and provides an equal quality of education for students in rural areas. A total of 60 Indonesian college students on selected campus (age 20 ± 0,36 years old) who joined the Computer Simulation class in the third grade participated in this study. They are divided into two classes, an online class using Moodle software and a physical class, then observations are made. This study aims to obtain preliminary data to then research what human factors influence Indonesian people that constrain students from successful participation in online learning. The results show that there are three aspects of implementing online lectures in Indonesia: rules, usability and cognitive aspects. Besides, quality of place is an environmental factor that cannot be controlled.

Sesgos cognitivos en anestesia, una causa latente de error humano / Cognitive biases in anesthesia, a latent cause of human error

Resumen: Un concepto que ha causado atención en los últimos años es el de los sesgos cognitivos y su influencia en las decisiones y comportamientos diarios de los seres humanos. Los equipos de trabajo en sala de operaciones se forman de diferentes áreas de especialidad y con distintos niveles de experiencia, todos tienen una función y pueden tomar decisiones que afectan al paciente. Este proceso de toma de decisiones se puede basar en experiencia previa, razonamiento clínico y el contexto; la necesidad de realizar diagnósticos y tratamiento rápido en algunas situaciones hace al anestesiólogo particularmente vulnerable a sesgos cognitivos. Presentamos diferentes ejemplos de sesgos cognitivos que se pueden llegar a presentar en sala de operaciones, como puede ser el sesgo de atención, en el cual un estímulo relevante como la necesidad de asegurar la vía aérea puede hacer que el estado hemodinámico del paciente pase desapercibido. El objetivo de este trabajo es crear conciencia particularmente en los anestesiólogos sobre estos sesgos cognitivos, su presencia en el proceso de toma de decisiones en la sala de operaciones y compartimos un par de formas para ayudar a prevenirlos.

Abstract: A concept that has gained attention in the last years is the existance of cognitive biases and their influence in decision making and behaviour of human beings. Teams in the operating room are formed by different medical specialities with varied levels of experience, everyone has a role and every one can make decisions that have an impact in the patient. This decision making process might be based in previous experience, clinical reasoning, and context; the need to make a rapid diagnosis and treatment in some situations makes the anesthesiologist especially vulnerable to cognitive bias. We present different types of cognitive bias that might be present in the operating room for example the attention bias in which a relevant stimulus like the airway management could make the hemodynamic aspect go unnoticed. The goal of this paper is to aware anesthesiologists in particular about this cognitive biases, their presence in the decision making process in the operating room and to share a couple of ways to prevent them.

Cognitive Model of a Semi-Mechanized Picking Operation / Modelo cognitivo de una operación de recolección semi-mecanizada / Modelo cognitivo de uma operação de colheita semimecanizada

Abstract Introduction: The current paper develops a pioneering approach to the human factors of picking operations, which are addressed from a cognitive perspective. Materials and methods: The model thus contributed is established through a qualitative methodology which, based on several theories, is articulated and applied to the real situation of a dry foods company's semi mechanized picking operation. Results: The results combine the cognitive architecture of the operation and its relations with logistic factors, in order to decrease human error and, therefore, increase service level. Conclusion: The current model provides elements for quantitative modeling, which could include this type of factors in order to optimize the picking operation of a supply chain.

Resumen Introducción: Este documento desarrolla un enfoque pionero sobre los factores humanos de las operaciones semi mecanizadas de selección, las cuales se abordan desde una perspectiva cognitiva. Materiales y métodos: El modelo aportado establece a través de una metodología cualitativa y a partir de varias teorías, es articulado y aplicado a la situación real de una operación de selección (picking semi) mecanizada de una empresa de alimentos secos. Resultados: Los resultados combinan la arquitectura cognitiva de la operación y sus relaciones con factores logísticos, para disminuir el error humano y, por lo tanto, aumentar el nivel de servicio. Conclusión: El modelo actual proporciona elementos para el modelado cuantitativo, el cual incluye este tipo de factores para optimizar la operación de picking de una cadena de suministro.

Resumo Introdução: Este documento desenvolve um enfoque pioneiro sobre os fatores humanos das operações semimecanizadas de seleção, as quais se abordam desde uma perspectiva cognitiva. Materiais e métodos: O modelo aportado estabelece através de uma metodologia qualitativa e a partir de várias teorias, é articulado e aplicado à situação real de uma operação de seleção (picking) semimecanizada de uma empresa de alimentos secos. Resultados: Os resultados combinam a arquitetura cognitiva da operação e suas relações com fatores logísticos, para diminuir o erro humano e, portanto, aumentar o nível de serviço. Conclusão: O modelo atual fornece elementos para modelagem quantitativa, que inclui este tipo de fatores para otimizar a operação de picking de uma cadeia de suprimentos.

Qualidade de Vida no Trabalho de motoristas e cobradores do transporte coletivo de Uberlândia / Quality of work life of drivers and bus collectors ofthe collective transportation of Uberlândia

Qualidade de Vida no Trabalho (QVT) é um tema presente na atualidade, porém existem categorias profissionais que foram pouco estudadas, como os motoristas e cobradores de ônibus. Assim, o objetivo geral do trabalho é investigar a percepção de Qualidade de Vida no Trabalho (QVT) dos motoristas e cobradores do transporte coletivo da cidade de Uberlândia utilizando o modelo de Hackman e Oldman (1975). Para tanto foi utilizada uma amostra de conveniência de 168 trabalhadores, sendo 54,2% motorista e 45,2% cobradores, 89,3% são do gênero masculino e com tempo médio de serviço de 34 meses (DP=25,11). Para aferir QVT foi utilizado um instrumento validado composto pelas quatro dimensões: Relações Interpessoais (RI, alfa=0,91), Segurança (S, alfa=0,85), Ambiente Físico Adequado (AFA, alfa=0,72) e Saúde Física (SF, alfa=0,71), com escala de resposta likert de sete pontos. Entre os aspectos avaliados, o mais presente foi AFA (M=4,65; DP=1,20) e o menos presente SF (M=2,46; DP=1,55). Os resultados não mostraram diferenças significativas na percepção de QVT em função do cargo, mas foram encontradas diferenças em função do tempo de serviço para RI, S e SF, sendo que os trabalhadores com mais tempo na organização possuem avaliação mais favorável. Os achados são cotejados com a literatura.

Quality of Life at Work (QWL) is a current theme, but there are professional categories that have been little studied, such as drivers and bus collectors. Thus, the main goal of the study is to investigate the perception of Quality of Life at Work (QWL) of drivers and collectors of collective transportation in the city of Uberlândia using the model of Hackman and Oldman (1975). For this purpose, a convenience sample of 168 workers was used, with 54,2% driver and 45,2% collectors, 89,3% are male and with an average service time of 34 months (SD = 25,11). In order to measure QWL, a validated instrument was used composed of four dimensions: Interpersonal Relations (IR, alpha = 0,91), Safety (S, alpha = 0,85), Adequate Physical Environment (APE, alpha = 0,72) and Physical Health (PH, alpha = 0,71), with a likert seven-point response scale. Among the evaluated aspects, APE (M = 4,65, SD = 1,20) and the least present PH (M = 2,46, SD = 1,55). The results did not show significant differences in the perception of QWL as a function of the position, but differences were found as a function of length of service for IR, S and PH, and the workers with more time in the organization have a more favorable evaluation. The findings are compared with the literature.

Effects of human and organizational deficiencies on workers' safety behavior at a mining site in Iran / 한국역학회지

OBJECTIVES: Throughout the world, mines are dangerous workplaces with high accident rates. According to the Statistical Center of Iran, the number of occupational accidents in Iranian mines has increased in recent years. This study investigated and analyzed the human and organizational deficiencies that influenced Iranian mining accidents.METHODS: In this study, the data associated with 305 mining accidents were analyzed using a systems analysis approach to identify critical deficiencies in organizational influences, unsafe supervision, preconditions for unsafe acts, and workers' unsafe acts. Partial least square structural equation modeling (PLS-SEM) was utilized to model the interactions among these deficiencies.RESULTS: Organizational deficiencies had a direct positive effect on workers' violations (path coefficient, 0.16) and workers' errors (path coefficient, 0.23). The effect of unsafe supervision on workers' violations and workers' errors was also significant, with path coefficients of 0.14 and 0.20, respectively. Likewise, preconditions for unsafe acts had a significant effect on both workers' violations (path coefficient, 0.16) and workers' errors (path coefficient, 0.21). Moreover, organizational deficiencies had an indirect positive effect on workers' unsafe acts, mediated by unsafe supervision and preconditions for unsafe acts. Among the variables examined in the current study, organizational influences had the strongest impact on workers' unsafe acts.CONCLUSIONS: Organizational deficiencies were found to be the main cause of accidents in the mining sector, as they affected all other aspects of system safety. In order to prevent occupational accidents, organizational deficiencies should be modified first.

Effects of human and organizational deficiencies on workers' safety behavior at a mining site in Iran / 한국역학회지

OBJECTIVES: Throughout the world, mines are dangerous workplaces with high accident rates. According to the Statistical Center of Iran, the number of occupational accidents in Iranian mines has increased in recent years. This study investigated and analyzed the human and organizational deficiencies that influenced Iranian mining accidents. METHODS: In this study, the data associated with 305 mining accidents were analyzed using a systems analysis approach to identify critical deficiencies in organizational influences, unsafe supervision, preconditions for unsafe acts, and workers' unsafe acts. Partial least square structural equation modeling (PLS-SEM) was utilized to model the interactions among these deficiencies. RESULTS: Organizational deficiencies had a direct positive effect on workers' violations (path coefficient, 0.16) and workers' errors (path coefficient, 0.23). The effect of unsafe supervision on workers' violations and workers' errors was also significant, with path coefficients of 0.14 and 0.20, respectively. Likewise, preconditions for unsafe acts had a significant effect on both workers' violations (path coefficient, 0.16) and workers' errors (path coefficient, 0.21). Moreover, organizational deficiencies had an indirect positive effect on workers' unsafe acts, mediated by unsafe supervision and preconditions for unsafe acts. Among the variables examined in the current study, organizational influences had the strongest impact on workers' unsafe acts. CONCLUSIONS: Organizational deficiencies were found to be the main cause of accidents in the mining sector, as they affected all other aspects of system safety. In order to prevent occupational accidents, organizational deficiencies should be modified first.

The Balance Between Safety and Productivity and its Relationship with Human Factors and Safety Awareness and Communication in Aircraft Manufacturing

BACKGROUND: This paper presents the findings of a pilot research survey which assessed the degree of balance between safety and productivity, and its relationship with awareness and communication of human factors and safety rules in the aircraft manufacturing environment. METHODS: The study was carried out at two Australian aircraft manufacturing facilities where a Likert-scale questionnaire was administered to a representative sample. The research instrument included topics relevant to the safety and human factors training provided to the target workforce. The answers were processed in overall, and against demographic characteristics of the sample population. RESULTS: The workers were sufficiently aware of how human factors and safety rules influence their performance and acknowledged that supervisors had adequately communicated such topics. Safety and productivity seemed equally balanced across the sample. A preference for the former over the latter was associated with a higher awareness about human factors and safety rules, but not linked with safety communication. The size of the facility and the length and type of employment were occasionally correlated with responses to some communication and human factors topics and the equilibrium between productivity and safety. CONCLUSION: Although human factors training had been provided and sufficient bidirectional communication was present across the sample, it seems that quality and complexity factors might have influenced the effects of those safety related practices on the safety–productivity balance for specific parts of the population studied. Customization of safety training and communication to specific characteristics of employees may be necessary to achieve the desired outcomes.

Human Error Probability Assessment During Maintenance Activities of Marine Systems

BACKGROUND: Maintenance operations on-board ships are highly demanding. Maintenance operations are intensive activities requiring high manemachine interactions in challenging and evolving conditions. The evolving conditions are weather conditions, workplace temperature, ship motion, noise and vibration, and workload and stress. For example, extreme weather condition affects seafarers' performance, increasing the chances of error, and, consequently, can cause injuries or fatalities to personnel. An effective human error probability model is required to better manage maintenance on-board ships. The developed model would assist in developing and maintaining effective risk management protocols. Thus, the objective of this study is to develop a human error probability model considering various internal and external factors affecting seafarers' performance. METHODS: The human error probability model is developed using probability theory applied to Bayesian network. The model is tested using the data received through the developed questionnaire survey of >200 experienced seafarers with >5 years of experience. The model developed in this study is used to find out the reliability of human performance on particular maintenance activities. RESULTS: The developed methodology is tested on the maintenance of marine engine's cooling water pump for engine department and anchor windlass for deck department. In the considered case studies, human error probabilities are estimated in various scenarios and the results are compared between the scenarios and the different seafarer categories. The results of the case studies for both departments are also compared. CONCLUSION: The developed model is effective in assessing human error probabilities. These probabilities would get dynamically updated as and when newinformation is available on changes in either internal (i.e., training, experience, and fatigue) or external (i.e., environmental and operational conditions such asweather conditions, workplace temperature, ship motion, noise and vibration, and workload and stress) factors.

The utility of live video capture to enhance debriefing following transcatheter aortic valve replacement.

Background: The surgical and procedural specialties are continually evolving their methods to include more complex and technically difficult cases. These cases can be longer and incorporate multiple teams in a different model of operating room synergy. Patients are frequently older, with comorbidities adding to the complexity of these cases. Recording of this environment has become more feasible recently with advancement in video and audio capture systems often used in the simulation realm. Aims: We began using live capture to record a new procedure shortly after starting these cases in our institution. This has provided continued assessment and evaluation of live procedures. The goal of this was to improve human factors and situational challenges by review and debriefing. Setting and Design: B‑Line Medical’s LiveCapture video system was used to record successive transcatheter aortic valve replacement (TAVR) procedures in our cardiac catheterization/laboratory. An illustrative case is used to discuss analysis and debriefing of the case using this system. Results and Conclusions: An illustrative case is presented that resulted in long‑term changes to our approach of these cases. The video capture documented rare events during one of our TAVR procedures. Analysis and debriefing led to definitive changes in our practice. While there are hurdles to the use of this technology in every institution, the role for the ongoing use of video capture, analysis, and debriefing may play an important role in the future of patient safety and human factors analysis in the operating environment.

Fatores e erros humanos na inspeção de segurança da aviação civil brasileira / Human factors and errors in the brazilian civil aviation security inspection / Los factores y errores humanos en la inspección de seguridad de la aviación civil brasileña

A área de security, e especificamente de security no canal de inspeção de segurança da aviação civil brasileira, apresenta carência de estudos quanto à identificação, à quantificação, à causa e ao impacto de fatores e erros humanos. Este estudo teve o objetivo de identificar os fatores e erros humanos envolvidos no processo de inspeção de segurança da aviação civil brasileira. Empregando-se a teoria do sistema geral de modelagem do erro - GEMS "Generic Error-Modelling System"- e os quatro eixos temáticos sobre fatores humanos preconizados pela Organização de Aviação Civil Internacional (OACI), elaborou-se o instrumento da pesquisa constituído por 60 questões. A amostra foi composta por 602 (seiscentos e dois) profissionais AVSEC (segurança da aviação civil contra atos de interferência ilícita) que laboram no canal de inspeção, distribuídos em 18 (dezoito) aeroportos brasileiros. Os resultados foram retratados por meio de estatística descritiva e Análise de Componentes Principais (ACP). Os principais pontos da etapa descritiva fazem referência ao tempo de serviço majoritário no canal de inspeção, ao grau de escolaridade e ao de rendimento mensal bruto. Após as etapas da ACP, 46 itens do questionário foram categorizados em 7 (sete) componentes principais, os quais representaram 42, 04% da proporção total da variância explicada dos dados, isto é, dos erros e fatores humanos pesquisados. Concluiu-se, a partir da ACP, que há incidência de fatores e erros humanos no processo de inspeção de segurança, cujos percentuais são retratados neste artigo.

This study aimed at identifying human factors and errors that may exist in the Brazilian civil aviation security inspection process. Employing the theory of the Generic Error Modeling System (GEMS) and the four themes about human factors recommended by the International Civil Aviation Organization - ICAO, the research instrument was formulated, being composed of 60 questions. The sample was composed of six hundred and two (602) AVSEC professionals (civil aviation security against acts of unlawful interference) who work in security check points, covering eighteen (18) Brazilian airports. The results were presented using descriptive statistics and Principal Components Analysis - PCA. The main points of the descriptive stage related to the preponderant length of service, level of education, and monthly income. After the PCA steps, 46 questionnaire items were categorized into seven (7) principal components, which represented 42.04% of the total variance being explained by the data. It was concluded from the PCA that there is incidence of human factors and errors in the security inspection process, whose percentages are described in this article.

El área de la seguridad, y, específicamente, en el canal de inspección de seguridad de la aviación civil brasileña, muestra carencia de estudios sobre la identificación, cuantificación, causas e impacto al respecto de errores y factores humanos. Este estudio tuvo como objetivo identificar los factores y los errores humanos que intervienen en el proceso de inspección de seguridad de la aviación civil brasileña. Al emplearse la teoría del sistema de modelación del error -GEMS "Generic Error - Modelling System- y de las cuatro áreas temáticas de los factores humanos recomendados por la Organización de Aviación Civil Internacional (OACI), se elaboró un instrumento de investigación constituido de 60 preguntas. La muestra consistió en 602 (seiscientos dos) profesionales AVSEC (seguridad de la aviación civil contra actos de interferencia ilícita), que trabajan en el canal de inspección de seguridad, repartidos en dieciocho (18) aeropuertos. Los resultados fueron retratados a través de estadística descriptiva y Análisis de Componentes Principales (ACP). Los puntos principales de la etapa descriptiva se refieren al tiempo de servicio en el canal de la inspección, el nivel de escolaridad y el ingreso bruto mensual. Tras los pasos de la ACP, 46 ítems del cuestionario fueron clasificados en 7 (siete) componentes principales, que representaron el 42.04% de la proporción total de varianza explicada de los datos. Se concluyó, a partir de la ACP, que hay incidencia de factores y errores humanos en el proceso de inspección de seguridad, cuyos porcentajes son retratados en este artículo.

Produção científica sobre fatores humanos no trabalho: análise a partir de periódicos brasileiros / Scientific production on human factors and work: analysis from brazilian scientific journals

A presente proposta de pesquisa trata do mapeamento do cenário científico brasileiro sobre a pesquisa de aspectos humanos no mundo do trabalho. O estudo foi realizado a partir de um levantamento de artigos publicados com temas ligados ao assunto dentro dos periódicos Brasileiros avaliados pela CAPES. Foram analisados no conjunto 178 artigos dentro de 15 revistas científicas nacionais ligadas ao campo da administração e psicologia indexadas à base de dados Scielo. A análise dos artigos considerou: avaliação das revistas, temas de estudo, metodologia e perfil dos autores. Os resultados mostram que a maior parte da publicação científica brasileira está concentrada em universidades e instituições públicas da região sul e sudeste, sob a responsabilidade de mestres e doutores. Os temas de maior ocorrência de estudos foram os seguintes: saúde mental, comportamento organizacional e identidade profissional.

This research proposal deals with the mapping of Brazilian scientific research on human aspects in the workplace. The study was conducted from a survey of articles published on topics related to the subject in the Brazilian journals evaluated by CAPES. A total of 178 articles in 15 national scientific journals related to the field of human factors in management and psychology were analyzed, all of which were indexed in the Scielo database. The analysis of the articles considered: evaluation of the journals, research themes, methodology, and author profiles. The results show that much of Brazilian scientific publication is concentrated in universities and public institutions in the South and Southeast regions, under the responsibility of masters and PhDs. The most frequent research topics were: mental health, organizational behavior, and professional identity.

Guiding medical equipment procurement by human factors engineering / 中华医院管理杂志

Human factors engineering is a promising interdisciplinary subject in applied sciences.This study presented the development and research purposes of human factors engineering.Based on case studies,the authors probed into the importance of the engineering in the design,management and procurement of medical equipments,for the purpose of optimizing medical equipment design,manufacturing and procurement.

Desafios da gestão coletiva da atividade na docência universitária / Challenges of the collective management activity in the universitary docency / Desafíos de la gestión colectiva de la actividad en la docencia universitaria

Este artigo objetiva analisar questões relativas à gestão coletiva da atividade docente no curso de Medicina de uma instituição federal de ensino superior, evidenciadas pela avaliação externa realizada pelo Ministério da Educação (MEC), e seu referencial teórico baseia-se nas abordagens da ergonomia e da psicodinâmica do trabalho. Trata-se de um estudo qualitativo do qual participaram dez docentes, oito homens e duas mulheres, de um total de cento e quarenta e nove existentes no curso de Medicina. O critério que serviu de base à composição desse grupo de pesquisa foi ter participado do processo de avaliação do curso de Medicina. Este estudo cumpriu as exigências éticas pertinentes à investigação que envolve seres humanos e sua estratégia metodológica combinou a realização de entrevistas não diretivas, gravadas sob autorização dos entrevistados, com a análise documental de relatórios de avaliação. Os resultados apontaram um engajamento profissional aquém do desejado em atividades de pesquisa e extensão e uma organização do trabalho que dificulta a consolidação dos coletivos e a manutenção de laços de cooperação entre os docentes, aspectos fundamentais para a qualidade e a produtividade, com saúde e segurança no trabalho...

This article aims to examine issues of collective management of teaching activities in the course of medicine of a federal institution of undergraduation, evidenced by the external evaluation conducted by the Ministry of Education (MEC), and The theoretical contributions were based on ergonomics and psychodynamics of work. It is a qualitative study attended by ten professors, eight men and two women, out of one hundred and forty-nine professors in Medicine. The criterion for the composition of the research group was the participation in the evaluation process of the medical school. This study followed the ethical requirements relevant to research involving human beings, and its methodological strategy combined nondirective interviews, recorded with the permission of the interviewees, with the documentary analysis of evaluation reports. The results pointed to a professional engagement that stays behind others in research and extension activities, and a work organization that hinders the consolidation of collectives and the maintenance of cooperative ties between teachers, key aspects of the issue of quality and productivity, with health and safety at work...

Este artículo tiene el objetivo de analizar cuestiones relativas a la gestión colectiva de la actividad docente en el curso de Medicina de una institución federal de enseñanza superior, evidenciadas por la evaluación externa realizada por el Ministerio de la Educación (MEC), y su referencial teórico se basa en los abordajes de la ergonomía y de la psicodinámica del trabajo. Se trata de un estudio cualitativo del cual participaron diez docentes, ocho hombres y dos mujeres, de un total de ciento cuarenta nueve existentes en el curso de Medicina. El criterio que sirvió de base para la composición de ese grupo de estudio fue haber participado del proceso de evaluación del curso de Medicina. Este estudio cumplió las exigencias éticas pertinentes a la investigación que involucra a seres humanos y su estrategia metodológica combinó la realización de entrevistas no directivas, grabadas bajo autorización de los entrevistados, con el análisis documental de informes de evaluación. Los resultados apuntaron un compromiso profesional por debajo de lo deseado en actividades de investigación y extensión y una organización del trabajo que dificulta la consolidación de los colectivos y el mantenimiento de lazos de cooperación entre los docentes, aspectos fundamentales para la calidad y la productividad, con salud y seguridad en el trabajo...

Human Factors Engineering in HI: So What? Who Cares? and What's in It for You? / 대한의료정보학회지

OBJECTIVES: Human factors engineering is a discipline that deals with computer and human systems and processes and provides a methodology for designing and evaluating systems as they interact with human beings. This review article reviews important current and past efforts in human factors engineering in health informatics in the context of the current trends in health informatics. METHODS: The methodology of human factors engineering and usability testing in particular were reviewed in this article. RESULTS: This methodology arises from the field of human factors engineering, which uses principles from cognitive science and applies them to implementations such as a computer-human interface and user-centered design. CONCLUSIONS: Patient safety and best practice of medicine requires a partnership between patients, clinicians and computer systems that serve to improve the quality and safety of patient care. People approach work and problems with their own knowledge base and set of past experiences and their ability to use systems properly and with low error rates are directly related to the usability as well as the utility of computer systems. Unusable systems have been responsible for medical error and patient harm and have even led to the death of patients and increased mortality rates. Electronic Health Record and Computerized Physician Order Entry systems like any medical device should come with a known safety profile that minimizes medical error and harm. This review article reviews important current and past efforts in human factors engineering in health informatics in the context of the current trends in health informatics.