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This thesis presents a new testbed for Automatic Incident Detection (AID) systems that uses real-time traffic video and data feeds from the Ministry of Transportation, Ontario (MTO) COMPASS Advanced Traffic Management System (ATMS). This new testbed, termed the AID Comparison and Analysis Tool (AID CAAT), consists largely of a data warehouse storing a significant amount of traffic video, the corresponding traffic data and an accurate log of incident start/end times. An evaluation was conducted whereby the AID CAAT was used to calibrate, and then analyze the performance of four AID systems: California Algorithm 8, McMaster Algorithm, the Genetic Adaptive Incident Detection (GAID) Algorithm and the Citilog - VisioPAD. The traditional measures of effectiveness (MOE) were initially used for this evaluation: detection rate (DR), false alarm rate (FAR), and mean time to detection (MTTD). However, an in-depth analysis of the test results (facilitated by the AID CAAT) revealed the need for two additional MOEs: False Normal Rate and Nuisance Rate. The justification and sample calculations for these new MOEs are also provided. This evaluation shows the considerable advantages of the AID CAAT, and also suggests the strengths and weaknesses of the AID systems tested. / Thesis / Master of Applied Science (MASc)

Remote usability evaluation is a usability evaluation method (UEM) where the experimenter, performing observation and analysis, is separated in space and/or time from the user. There are several approaches by which to implement remote evaluation, limited only by the availability of supporting technology. One such implementation method is RECITE (the REmote Critical Incident TEchnique), an adaptation of the user-reported critical incident technique developed by Castillo (1997). This technique requires that trained users, working in their normal work environment, identify and report critical incidents. Critical incidents are interactions with a system feature that prove to be particularly easy or difficult, leading to extremely good or extremely poor performance. Critical incident reports are submitted to the experimenter using an on-line reporting tool, who is responsible for their compilation into a list of usability problems. Support for this approach to remote evaluation has been reported (Hartson, H.R., Castillo, J.C., Kelso, J., and Neale, W.C., 1996; Castillo, 1997). The purpose of this study was to quantitatively assess the effectiveness of RECITE with respect to traditional, laboratory-based applications of the critical incident technique. A 3x2x 5 mixed-factor experimental design was used to compare the frequency and severity ratings of critical incidents reported by remote versus laboratory-based users. Frequency was measured according to the number of critical incident reports submitted and severity was rated along four dimensions: task frequency, impact on task performance, impact on satisfaction, and error severity. This study also compared critical incident data reported by trained users versus by usability experts observing end-users. Finally, changes in critical incident data reported over time were evaluated. In total, 365 critical incident reports were submitted, containing 117 unique usability problems and 50 usability success descriptions. Critical incidents were classified using the Usability Problem Inspector (UPI). A higher number of web-based critical incidents occurred during Planning than expected. The distribution of voice-based critical incidents differed among participant groups: users reported a greater than expected number of Planning incidents while experts reported fewer than expected Assessment incidents. Usability expert performance was not correlated, requiring that separate analyses be conducted for each expert data set. Support for the effectiveness in applying critical incidents to remote usability was demonstrated, with all research hypotheses at least partially supported. Usability experts gave significantly different ratings of impact on task performance than did user reporters. Remote user performance versus laboratory-based users failed to reveal differences in all but one measure: laboratory-based users reported more positive critical incidents for the voice interface than did remote users. In general, the number of negative critical incidents decreased over time; a similar result did not apply to the number of positive critical incidents. It was concluded that RECITE is an effective means of capturing problem-oriented data over time. Recommendations for its use as a formative evaluation method applied during the latter stages of product development (i.e. when a high fidelity prototype is available) are made. Opportunities for future research are identified. / Master of Science

No / Drug errors are a common and persistent problem in health care and are also associated with serious adverse events. Reporting has become the cornerstone of learning from errors, but is not without its imperfections. The aim of this study is to improve reporting and learning from drug errors through investigating the contributory factors in drug errors and quality of reporting in an acute hospital. Methods: A retrospective, random sample of 991 drug error reports from 1999 to 2003 were subjected to quantitative and qualitative analysis. This was followed by 40 qualitative interviews with a volunteer, multi‐disciplinary sample of health professionals. The combined analysis has been used to develop a knowledge base for improved drug error reporting. Results: The quality of reports varied considerably, and 27% of reports lacked any contributory factors. Documentary analysis revealed a focus on individuals, sometimes culminating in blame without obvious justification. Doctors submitted few reports, and there were notable differences in reporting according to clinical location. Communication difficulties commonly featured in causation, and high workload and interruptions were predominant contributory factors in the interview data. Interviewees viewed causation as multifactorial, including cognitive and psychosocial factors. Organizational orientation to error was predominantly perceived by interviewees as individual rather than systems‐based. Staff felt obliged to report but rarely received feedback. Implications and conclusio: Drug errors are multifactorial in causation. Current reporting schemes lack a theoretical basis, and are unlikely to capture the information required to ensure learning about causation. Health professionals have reporting fatigue and some remain concerned that reporting promotes individual blame rather than an examination of systems factors. Reporting can be strengthened by human error theory, redesigned to capture a range of contributory factors, facilitate learning and foster supportive actions. It can also be feasible in routine practice. Such an approach should be examined through multi‐centred evaluation.

This study was designed to determine the ability of the Critical Incident Technique (CIT) to advise changes to training regiments offered to Resident Advisers (RAs). The CIT was devised as a tool in the field of organizational psychology. Its purpose is to assist in analyzing the success of individual team members by examining the self-reported occurrence of incidents on the job, which are deemed critical. The Critical Incident Technique has been implemented with success in business and military applications. This powerful tool allows researchers to make valuable observations about the realities faced by individuals on the job. These observations make it possible to devise and improve existing training methods capitalizing on these realities. Data for this study came from an examination of incident reports (IRs). RAs generate IRs in response to different kinds of issues faced working with resident college students. Three regional institutions agreed to participate in this study and helped to diversify the data collected. This study addresses the following questions: What are the critical incidents RAs experience most often on the job? Is there a difference between the critical incident types reported in residence halls by institutional type? Is there a difference between the critical incident types reported by hall types? Is there a difference between the critical incident types reported by gender? What implications do the findings have for future RA training? Four types of demographic information were collected from the IRs: institution type (large public, midsize public, and small private), hall type (male, female, or coed), RA gender, and incident type. Conducting a survey of the literature concerning RA training and the CIT, generated five general categories of incidents on which RAs report. Crisis situations Policy enforcement Facilities management Administrative procedures Advising Specific measures including coding, and excision of sensitive information (such as sexual assaults sexual identity situations) from documents were used to protect the confidentiality and anonymity of the parties involved. When data collection was complete, a chi-squared test of significance was used to examine the relationships between the incident types reported and each of the other three variables (gender, institution type, and hall type). After analyzing the data using the statistical research methods described above, it was possible to make recommendations for future RA training. This study examines the impact of institutional environment, department philosophy, and personal bias on the training of RAs. The results suggest that each of these factors influences the success of RAs, and defines the environments in which resident students live. / Master of Arts

Denna studie är en kvalitativ studie med syftet att undersöka hur en nöjespark i Sverige arbetar med förebyggande risk- och krishantering. Nöjesparken som har undersökts är Liseberg som ligger i Göteborg. En fallstudie på Liseberg har gjorts med hjälp av kvalitativa metoder och ett deduktivt förhållningssätt. Fem semistrukturerade intervjuer gjordes med fyra personer från Lisebergs företagsledning samt en person från företaget Göteborg: Co. Studien baseras även på sju mailintervjuer med parkmedarbetare på Liseberg. Studiens resultat visar att organisationen följer de kriterier som de valda teorierna förespråkar att en organisation bör följa. Både i förebyggande syfte men även hur en kris ska hanteras när den inträffar. Lisebergs främsta värdeord är säkerhet, vilket återspeglar deras arbete kring säkerhetsfrågor. De övningar och utbildningar inom risk- och krishantering som de anställda på nöjesparken genomgår kan ses som otillräckliga. Detta kan leda till att en kris inte kommer kunna hanteras på det mest effektiva sättet. Resultatet för denna studie visar alltså att Liseberg teoretiskt skulle klara av de flesta risker och kriser. Studien går att applicera på andra nöjesparker samt liknande turistföretag vilket är positivt för att i dagens forskning fylla de luckor som finns inom detta forskningsområde. / The purpose of this study is to investigate how a theme park in Sweden works with preventive risk management, and how they handle crisis management in case of incidents. The theme park which has been studied is located in the city Gothenburg and is called Liseberg. A field study of Liseberg has been made with a qualitative research. Five semi -structured interviews have been held in Gothenburg and seven mail interviews have been held to collect the empirical results. The results shows that Lisebergs risk and crisis management sees at the current situation on paper to be able to handle most types of incidents. The organization follows the criteria according to what the theories in the study says an organization should follow, both preventively and how the actions when an incident occurs should be taken. Training in risk and crisis management, however, is considered low for all employees to be able to handle major incidents. This may mean that a crisis is not handled in the most efficient way. The study can be applied to other amusements parks and similar tourist companies which is positive for the current research to fill the gaps contained in this research area.

Improving patient safety through reduction of medical errors is a national priority. One of the strategies widely utilized to address this issue is the use of incident reporting systems. The purpose of this study was to describe factors that predict the likelihood that Certified Registered Nurse Anesthetists (CRNAs) will use incident reporting systems, guided by the theory of planned behavior (Ajzen, 1991). A non-experimental, correlational research design was utilized to achieve the study aims. Following IRB approval, a cross-sectional survey was administered electronically to a random sample of practicing CRNAs. Correlational analyses and a standard logistic regression were utilized to determine the relationship between cognitive factors and CRNAs' use of incident reporting systems. Two hundred and eighty-three practicing CRNAs participated in this study. These CRNAs value incident reporting, perceive social pressure to report, and feel in control over reporting, yet had not consistently used existing incident reporting systems in the past 12 months. A CRNA’s attitude toward reporting and the degree to which he or she perceived social pressure to report, were determined to be significant predictors of the likelihood that a CRNA would use an incident reporting system. Social pressure to report was the most important factor in the prediction model. The results of this study revealed that there are missed opportunities for learning from patient safety incidents in anesthesia practice. The information gained in this study has the potential to assist organizations in the design of strategies to promote incident reporting by practicing CRNAs.

Explaining incidents as systems is a fast growing area of safety scientific research. The misleading conception of naturalistic human communication in terms of 'objective information' remains a pervasive influence on systemic explanation of incidents, despite over a decade of methodological developments in the area. Currently, interested stakeholders are offered with few alternatives for analysing how information systems emerge naturally, and contribute towards the structuring of incident situations. Extant methods are also yet to be widely adopted by the practitioner community, and a research-practice gap has formed. In this PhD research, a new method of systemic incident analysis is developed, to counterbalance against the extant methods being developed in the area. The new method draws on insights from both Distributed Cognition, and linguistics research, in order to present a distributed means of doing systemic incident analysis. The new method de-objectifies the notion of information, to support analysis of how information 'flow' is constitutive of the formation of distributed cognitive systems. In embedding an intersubjective component into the core method design, we aim to increase the likelihood of systematic learning from incident situations. The incident analyst is required to explicitly relate past explanations of incident situations, in detail, to data and hypotheses from new incident situations. To increase the potential for theorists in the area to better account for the demands of incident analysis as practiced, data, insights, and method are contributed towards the bridges been built between research and practice. We first develop additional understanding of the practice of incident analysts from the patient safety background. Next, we provide a second new method of analysis, to allow research scrutiny of the empirical phenomena of using systemic incident analysis methods. This second method considers the detailed relationship: from the theory of the systemic incident analysis method into its practice as part of real incident investigation. This provides a new research instrument, for systematically examining how systemic incident analysis methods may afford or constrain elements of their practice.

The aim of this Master’s thesis is to investigate if the library can be a real partner for researchers in managing and dealing with their research information. In this study, six researchers have been interviewed about their problems with information management. This study uses the method Critical Incident Technique for the interviews with the researchers. This method focuses mainly on problems and what happens around those problems. The interview results have been prepared with automatic clustering and analysed with the help of a theoretical model from Minnesota University Library. This is a model of the scholarly research process described in four overlapping areas: 1) Discover, 2) Gather, 3) Create and 4) Share. The studies result gives that there seems to be no problem with accessing full text information, the problem is rather narrowing down the search to get enough time to read it all. The researchers do not find any search skills in the library that match their own search skills. On the question if the library works well as a partner, the answer in this study is no. The researchers do not see the library as a partner in working with research information, but only as a supplier of documents. When they need assistance, they turn to colleagues, students, email, and as a last resort, the library.