Errors during radiotherapy treatment can cause severe, and potentially fatal, patient harm. The final check immediately prior to treatment delivery, whereby two radiographers ensure that the dose about to be delivered corresponds with the prescription, is the last defence against error. The aim of this research was to increase understanding of this final treatment check and factors affecting error detection, in order to improve the safety of radiotherapy treatment delivery. The research adopted a mixed methods approach, combining qualitative and experimental studies to investigate the interaction of factors affecting accuracy during the final treatment checks. The qualitative interviews and task analysis pointed to difficulties maintaining attention and variation in how these checks are conducted. The interface used to conduct the final treatment check was also recognised to have usability issues. The laboratory-based experimental studies results indicated that a structured form of double checking, called challenge-response, is most effective at error detection, when compared to single or unstructured double checking. Furthermore, it was found that alternating the roles of challenger and responder, and the order parameters are checked in, significantly increases accuracy during repeated treatment checks. The original contribution of this research was a detailed investigation of a previously understudied aspect of radiotherapy treatment. The results informed the design of an original, evidence and theoretical based two-person checking protocol for use during the final treatment check. Qualitative evaluation indicates that it would be well received as a standardised method of treatment checking. Furthermore, an alternative interface design has been proposed, specifically for use during the final treatment check. This was comparatively tested against the most frequently used software package within the UK and found to have a significant positive impact upon user’s accuracy. An additional output is a series of practice based recommendations to improve accuracy during repeated treatment checking. This research has concluded that implementation of the practice recommendations, checking protocol and interface design should help maintain radiographers’ attention during repeated final treatment checks, thereby preventing errors passing undetected. Future research into the radiotherapy interface design and implementation of the standardised final treatment check protocol have been identified.

Master of Agribusiness / Department of Agricultural Economics / Vincent R. Amanor-Boadu / It is estimated that the animal health biologics sector will increase by over 27% between 2015 and 2020. This projection and the increasing competition among the sector’s players suggests need to find ways to enhance their efficiencies in manufacturing to sustain their relative competitiveness. One approach to enhancing efficiencies is to ensure that all work is done once, i.e., everything is done right the first time. This research focused on human error as a major source of inefficiency in manufacturing and hypothesized that addressing issues that reduce human error would contribute to reducing inefficiencies. The research used the Kaizen process to assess the before and after counts of human error in a biologics manufacturing unit of Z Animal Health Company (ZAHC). The study found that human error accounted for about 51% of all sources of error in the pre-Kaizen period and only about 34% of all errors in the post-Kaizen period, a reduction in excess of 33.3%. Given that humans are directly or indirectly responsible for all activities in the manufacturing process, the Kaizen process also contributed to a reduction in most other error sources. For example, errors in raw materials and components went reduced by about 50%. We tested the hypothesis that undertaking the Kaizen was statistically effective in reducing human error compared to all other errors using a logit model. Our results confirmed this hypothesis, showing that the odds ratio of human error in the post-Kaizen period was about 50% of the odds of non-human error. The research suggests that in a highly technical manufacturing environment, such as in animal health biologics, human errors can be a major problem that can erode competitiveness quickly. Focusing employees’ on root causes of errors and helping them address these through structured quality-enhancing initiatives such as Kaizen produce superior results. It is, therefore, suggested that when organizations discover human error as a major source of inefficiency, it is prudent to help employees understand what they do and how what they do contributes to the overall performance of the organization. This appreciation of how their actions fit into the big picture could provide a foundation upon which significant improvements can be achieved.

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Cooper and Shallice (2000) implemented a computational version of the Norman and Shallice’s (1986) Contention Scheduling Model (CSM). The CSM is a hierarchically organized network of action schemas and goals. Botvinick and Plaut (2004) instead took a connectionist approach to modeling routine procedural behavior. They argued in favor of holistic, distributed representation of learned step co-occurrence associations. Two experiments found that people can adapt routine procedural behavior to changing circumstances quite readily and that other factors besides statistical co-occurrence can have influence on action selection. A CSM-inspired ACT-R model of the two experiments is the first to postdict differential error rates across multiple between-subjects conditions and trial types. Results from the behavioral and modeling studies favor a CSM-like theory of human routine procedural memory that uses discrete, hierarchically-organized goal and action representations that are adaptable to new but similar procedures. / Office of Naval Research grants #N00014-03-1-0094 and #N00014-06-1-0056

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The master thesis is focused on the reliability of the human factor in the operation of the production machine. In the first part the basic legislative requirements for safety and reliability of work are presented. In the second part, the reliability of the human factor is discussed along with a description of selected methods for assessing the reliability of the human factor. The research section then concludes with a proposed methodology for human factors assessment for the manufacturing process. In the practical part, the proposed methodology is applied to the selected process, which includes risk identification and outputs from the selected methods. The thesis then concludes by recommending preventive measures to eliminate the identified risks.

The aim of the thesis was to develop and evaluate a Computerised Decision Support System (CDSS) for use in pre-hospital care.The thesis was guided by a theoretical framework for developing and evaluating a complex intervention. The four studies used different designs and methods. The first study was a systematic review of randomised controlled trials. The second and the last studies had experimental and quasi-experimental designs, where the CDSS was evaluated in a simulation setting and in a clinical setting. The third study included in the thesis had a qualitative case study design.The main findings from the studies in the thesis were that there is a weak evidence base for the use of CDSS in pre-hospital care. No studies have previously evaluated the effect of CDSS in pre-hospital care. Due to the context, pre-hospital care is dependent on protocol-based care to be able to deliver safe, high-quality care. The physical format of the current paper based guidelines and protocols are the main obstacle to their use. There is a request for guidelines and protocols in an electronic format among both clinicians and leaders of the ambulance organisations. The use of CDSS in the pre-hospital setting has a positive effect on compliance with pre-hospital guidelines. The largest effect is in the primary survey and in the anamnesis of the patient. The CDSS also increases the amount of information collected in the basic pre-hospital assessment process. The evaluated CDSS had a limited effect on on-the-scene time.The developed and evaluated CDSS has the ability to increase pre-hospital patient safety by reducing the risks of cognitive bias. Standardising the assessment process, enabling explicit decision support in the form of checklists, assessment rules, differential diagnosis lists and rule out worst-case scenario strategies, reduces the risk of premature closure in the assessment of the pre-hospital patient. / För avläggande av doktorsexamen i Kvalitetsförbättring och ledarskap inom hälsa och välfärd som med tillstånd av Nämnden för utbildning och forskarutbildning vid Högskolan i Jönköping framläggs till offentlig granskning torsdagen den 5 juni 2014 kl.13.00 i sal M 204, Högskolan i Borås.

Background: Concern has been raised that the workload of community pharmacists (CPs) is linked to the occurrence of dispensing errors (DEs). One aspect of workload that has not yet been measured in this setting, but has been linked to errors in other industries, is mental workload (MWL). Aims: (1) Measure the relationship between MWL and DEs during a routine pharmacy task, the final accuracy check, which research suggests is critical to DE prevention. (2) Quantify the role that expertise plays in this relationship. (3) Explore CPs and pharmacy students’ experiences of MWL and DEs. Methods: A mixed methods approach was taken and three studies were conducted. In study one, CPs (n=104) and students (n=93) checked dispensed items for DEs. Participants took part in one of four conditions (distraction, no distraction, dual-task or single-task) and their DE detection and MWL was measured. Study two was a diary study of CPs’ (n=40) MWL during a day in their “real-life” practice. Study three presented an interpretative phenomenological analysis of CPs’ (n=14) and students’ (n=15) experiences of MWL and DEs. Main findings: Study one found that high MWL was related to reduced DE detection, but only for students, confirming the important role of expertise. Distractions did not affect DE detection but was linked to increased MWL. Study 2 highlighted specific times of the day when CPs’ MWL was exceptionally high. Study 3 found several factors which increased MWL, including the lack of control CP’s had over their workload, difficulties communicating with prescribers and targets. Conclusions: MWL has been found to be a useful tool for measuring the impact of workload on pharmacy safety. The findings are linked to current work design and human factors theory and suggestions are made for how CPs’ work could be redesigned to reduce their MWL and improve safety.

Neste trabalho foram obtidas estimativas das Probabilidades de Erro Humano (PEH) das ações dos operadores do Reator de Pesquisa IEA-R1 do IPEN, em resposta a uma hipótese de situação de emergência, e realizada uma avaliação dos Fatores Influenciadores do Desempenho Humano (PSF) potencialmente influentes naquelas ações. A avaliação dos PSF foi realizada com a finalidade de classificá-los de acordo com o seu nível de influência nas ações e de determinar o estado atual destes PSF na instalação. Tanto a obtenção das PEH, como também a avaliação dos PSF, foram realizadas por meio do processo de Avaliação por Especialistas, através de entrevistas e questionários. O grupo especialista foi composto a partir dos próprios operadores do Reator IEA-R1. A representação do conhecimento dos especialistas em expressões lingüísticas e a geração de valores que representam o consenso das avaliações do grupo especialista deram-se pelo emprego da Lógica Fuzzy e da Teoria dos Conjuntos Fuzzy. Os valores obtidos para as PEH foram comparados com dados utilizados pela literatura afim e se mostraram satisfatórios para ações similares, corroborando a metodologia proposta como uma boa alternativa a ser empregada em métodos de Análises de Confiabilidade Humana (ACH). / This work obtains Human Error Probability (HEP) estimates from operator\'s actions in response to emergency situations a hypothesis on Research Reactor IEA-R1 from IPEN. It was also obtained a Performance Shaping Factors (PSF) evaluation in order to classify them according to their influence level onto the operator\'s actions and to determine these PSF actual states over the plant. Both HEP estimation and PSF evaluation were done based on Specialists Evaluation using interviews and questionnaires. Specialists group was composed from selected IEA-R1 operators. Specialist\'s knowledge representation into linguistic variables and group evaluation values were obtained through Fuzzy Logic and Fuzzy Set Theory. HEP obtained values show good agreement with literature published data corroborating the proposed methodology as a good alternative to be used on Human Reliability Analysis (HRA).