Adaptation of the standardized plant analysis–risk human reliability analysis technique for the surgical setting: expert judgment approach

References

• Jahangiri M, Hoboubi N, Rostamabadi A, et al. Human error analysis in a permit to work system: a case study in a chemical plant. Saf Health Work. 2016;7(1):6–11. doi:10.1016/j.shaw.2015.06.002
   PubMed Web of Science ®Google Scholar
• Liu P, Qiu Y, Hu J, et al. Expert judgments for performance shaping factors’ multiplier design in human reliability analysis. Reliab Eng Syst Saf. 2020;194:106343. doi:10.1016/j.ress.2018.12.022
   Web of Science ®Google Scholar
• Swain AD, Guttmann HE. Handbook of human-reliability analysis with emphasis on nuclear power plant applications. Final report. Albuquerque (NM): Sandia National Labs; 1983.
   Google Scholar
• Bell J, Holroyd J. Review of human reliability assessment methods. Buxton: Health and Safety Executive; 2009. (Report No. RR679).
   Google Scholar
• Kirwan B, Gibson H, Kennedy R, et al. Nuclear action reliability assessment (NARA): a data-based HRA tool. In: Kirwan B, Gibson H, Kennedy R, Edmunds J, Cooksley G, Umbers I, editors. Probabilistic safety assessment and management. London: Springer; 2004. p. 1206–1211. doi:10.1007/978-0-85729-410-4_195
   Google Scholar
• Bye A, Laumann K, Taylor C, et al. The petro-HRA guideline. Trondheim: Institute for Energy Technology; 2017. (IFE/HR/E-2017/001).
   Google Scholar
• Kirwan B, Gibson H. CARA: a human reliability assessment tool for air traffic safety management – technical basis and preliminary architecture. In: Kirwan B, Gibson H, editors. The safety of systems. Springer; 2007. p. 197–214. doi:10.1007/978-1-84628-806-7_13
   Google Scholar
• Rasmussen M, Laumann K. The evaluation of fatigue as a performance shaping factor in the petro-HRA method. Reliab. Eng Syst Saf. 2020;194(1):106187. doi:10.1016/j.ress.2018.06.015
   Google Scholar
• Griffith CD, Mahadevan S. Inclusion of fatigue effects in human reliability analysis. Reliab Eng Syst Saf. 2011;96(11):1437–1447. doi:10.1016/j.ress.2011.06.005
   Web of Science ®Google Scholar
• Griffith CD, Mahadevan S. Human reliability under sleep deprivation: derivation of performance shaping factor multipliers from empirical data. Reliab Eng Syst Saf. 2015;144:23–34. doi:10.1016/j.ress.2015.05.004
   Web of Science ®Google Scholar
• Onofrio R, Trucco P. Human reliability analysis (HRA) in surgery: identification and assessment of Influencing factors. Saf Sci. 2018;110(A):110–123. doi:10.1016/j.ssci.2018.08.004
   Google Scholar
• Lyons M. Towards a framework to select techniques for error prediction: supporting novice users in the healthcare sector. Appl Ergon. 2009;40(3):379–395. doi:10.1016/j.apergo.2008.11.004
   PubMed Web of Science ®Google Scholar
• Lyons M, Adams S, Woloshynowych M, et al. Human reliability analysis in healthcare: a review of techniques. Int J Risk Saf Med. 2004;16(4):223–237.
   Google Scholar
• Chadwick L, Fallon EF. Human reliability assessment of a critical nursing task in a radiotherapy treatment process. Appl Ergon. 2012;43(1):89–97. doi:10.1016/j.apergo.2011.03.011
   PubMed Web of Science ®Google Scholar
• Liu P, Lyu X, Qiu Y, et al. Identifying key performance shaping factors in digital main control rooms of nuclear power plants: a risk-based approach. Reliab Eng Syst Saf. 2017;167:264–275. doi:10.1016/j.ress.2017.06.002
   Web of Science ®Google Scholar
• Laumann K, Rasmussen M. Suggested improvements to the definitions of standardized plant analysis of risk–human reliability analysis (SPAR-H) performance shaping factors, their levels and multipliers and the nominal tasks. Reliab Eng Syst Saf. 2016;145:287–300. doi:10.1016/j.ress.2015.07.022
   Web of Science ®Google Scholar
• Eyvazlou M, Dadashpour Ahangar A, Rahimi A, et al. Human reliability assessment in a 99Mo/99mTc generator production facility using the standardized plant analysis risk-human (SPAR-H) technique. Int J Occup Saf Ergon. 2019;25(2):321–330. doi:10.1080/10803548.2017.1415832
   PubMed Web of Science ®Google Scholar
• Kirwan B. A guide to practical human reliability assessment. 1st ed. London: CRC; 1994.
   Google Scholar
• Cooper S, Ramey-Smith A, Wreathall J, et al. A technique for human error analysis (ATHEANA). Washington (DC): Nuclear Regulatory Commission; 1996. (NUREG/CR–6350).
   Google Scholar
• Pan X, Wu Z. Performance shaping factors in the human error probability modification of human reliability analysis. Int J Occup Saf Ergon. 2020;26(3):538–550. doi:10.1080/10803548.2018.1498655
   PubMed Web of Science ®Google Scholar
• Quigley J, Hardman G, Bedford T, et al. Merging expert and empirical data for rare event frequency estimation: pool homogenisation for empirical Bayes models. Reliab Eng Syst Saf. 2011;96(6):687–695. doi:10.1016/j.ress.2010.12.007
   Web of Science ®Google Scholar
• Grozdanovic M. Usage of human reliability quantification methods. Int J Occup Saf Ergon. 2005;11(2):153–159. doi:10.1080/10803548.2005.11076644
   PubMedGoogle Scholar
• Hollnagel E. Cognitive reliability and error analysis method (CREAM). 1st ed. Halden: Elsevier; 1998.
   Google Scholar
• Hollnagel H. Reliability analysis and operator modelling. Reliab Eng Syst. 1996;52(3):327–337. doi:10.1016/0951-8320(95)00143-3
   Web of Science ®Google Scholar
• Cooke RM, Goossens LH. Expert judgement elicitation for risk assessments of critical infrastructures. J Risk Res. 2004;7(6):643–656. doi:10.1080/1366987042000192237
   Web of Science ®Google Scholar
• Narens L. A theory of ratio magnitude estimation. J Math Psychol. 1996;40(2):109–129. doi:10.1006/jmps.1996.0011
   Web of Science ®Google Scholar
• Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med. 2016;15(2):155–163. doi:10.1016/j.jcm.2016.02.012
   PubMed Web of Science ®Google Scholar
• Gertman D, Blackman H, Marble J, et al. The SPAR-H human reliability analysis method. Poster session presented at: Fourth American Nuclear Society International Topical Meeting on Nuclear Plant Instrumentation, Controls and Human–Machine Interface Technologies (NPIC&HMIT 2004); 2004 Sep 1–8; Columbus (OH).
   Google Scholar
• Boring R, Whaley A, Tran T, et al. Guidance on performance shaping factor assignments in SPAR-H. Washington (DC): Idaho National Laboratory; 2011. (INL/EXT-10-18533).
   Google Scholar
• Keinan G. Decision making under stress: scanning of alternatives under controllable and uncontrollable threats. J Pers Soc Psychol. 1987;52(3):639–644. doi:10.1037/0022-3514.52.3.639
   PubMed Web of Science ®Google Scholar
• McQueen S, Mobilio MH, Moulton C. Fractured in surgery: understanding stress as a holistic and subjective surgeon experience. Am J Surg. 2021;221(4):793–798. doi:10.1016/j.amjsurg.2020.04.008
   PubMed Web of Science ®Google Scholar
• Liu P, Li Z. Comparison between conventional and digital nuclear power plant main control rooms: a task complexity perspective, part I: overall results and analysis. Int J Ind Ergon. 2016;51:2–9. doi:10.1016/j.ergon.2014.06.006
   Web of Science ®Google Scholar
• Carayon P, Hundt AS, Karsh B, et al. Work system design for patient safety: the SEIPS model. BMJ Qual Saf. 2006;15(Suppl 1):50–58. doi:10.1136/qshc.2005.015842
   Google Scholar
• Lazzara EH, Pavlas D, Fiore S, et al. A framework to develop task complexity. In: Proceedings of the Human Factors and Ergonomics Society Annual Meeting; 2010 Sep 1; Los Angeles (CA): SAGE; 2010. p. 2338–2342.
   Google Scholar
• Liu P, Lv X, Li Z, et al. Conceptualizing performance shaping factors in main control rooms of nuclear power plants: a preliminary study. In: Liu P, Lv X, Li Z, Qiu Y, Hu J, He J, editors. Paper presented at: International Conference on Engineering Psychology and Cognitive Ergonomics; 2016 Jun 21; Switzerland. Toronto: Springer; 2016. p. 322–333.
   Google Scholar
• Toriizuka T. Application of performance shaping factor (PSF) for work improvement in industrial plant maintenance tasks. Int J Ind Ergon. 2001;28(3–4):225–236. doi:10.1016/S0169-8141(01)00036-1
   Web of Science ®Google Scholar
• Rasmussen M, Standal MI, Laumann K. Task complexity as a performance shaping factor: a review and recommendations in standardized plant analysis risk–human reliability analysis (SPAR-H) adaption. Saf Sci. 2015;76:228–238. doi:10.1016/j.ssci.2015.03.005
   Web of Science ®Google Scholar
• Sturman MC. Searching for the inverted U-shaped relationship between time and performance: meta-analyses of the experience/performance, tenure/performance, and age/performance relationships. J Manage. 2003;29(5):609–640.
   Web of Science ®Google Scholar
• Westbrook JI, Woods A, Rob MI, et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med. 2010;170(8):683–690. doi:10.1001/archinternmed.2010.65
   PubMedGoogle Scholar
• Coldiron B. Office surgical incidents: 19 months of Florida data. Dermatol Surg. 2002;28(8):710–713.
   PubMed Web of Science ®Google Scholar
• Coldiron BM, Healy C, Bene NI. Office surgery incidents: what seven years of Florida data show us. Dermatol Surg. 2008;34(3): 285–292.
   PubMed Web of Science ®Google Scholar
• Santell JP. Medication errors: experience of the United States Pharmacopeia (USP). Jt Comm J Qual Patient Saf. 2005;31(2):114–119.
   PubMedGoogle Scholar
• Gorgich EAC, Barfroshan S, Ghoreishi G, et al. Investigating the causes of medication errors and strategies to prevention of them from nurses and nursing student viewpoint. Glob J Health Sci. 2016;8(8):220–227. doi:10.5539/gjhs.v8n8p220
   Google Scholar
• Chase B, Karwowski W, Benedict ME, et al. Effects of thermal stress on dual task performance and attention allocation. Hum Perf Extrem Environ. 2005;8(1):27–39.
   Google Scholar
• Hancock PA, Ross JM, Szalma JL. A meta-analysis of performance response under thermal stressors. Hum Factors. 2007;49(5):851–877. doi:10.1518/001872007X230226
   PubMed Web of Science ®Google Scholar
• Ahmed Z, Saada M, Jones AM, et al. Medical errors: healthcare professionals’ perspective at a tertiary hospital in Kuwait. PloS one. 2019;14(5):1–14.
   Web of Science ®Google Scholar
• Krueger GP. Sustained work, fatigue, sleep loss and performance: a review of the issues. Work & Stress. 1989;3(2):129–141. doi:10.1080/02678378908256939
   Web of Science ®Google Scholar
• Dinges DF. An overview of sleepiness and accidents. J Sleep Res. 1995;4:4–14. doi:10.1111/j.1365-2869.1995.tb00220.x
   PubMed Web of Science ®Google Scholar
• Filtness AJ, Naweed A. Causes, consequences and countermeasures to driver fatigue in the rail industry: the train driver perspective. Appl Ergon. 2017;60:12–21. doi:10.1016/j.apergo.2016.10.009
   PubMed Web of Science ®Google Scholar
• Harrison Y, Horne JA. The impact of sleep deprivation on decision making: a review. J Exp Psychol Appl. 2000;6(3):236–249. doi:10.1037/1076-898X.6.3.236
   PubMed Web of Science ®Google Scholar
• Williamson A, Lombardi DA, Folkard S, et al. The link between fatigue and safety. Accid Anal Prev. 2011;43(2):498–515. doi:10.1016/j.aap.2009.11.011
   PubMed Web of Science ®Google Scholar
• Whaley AM, Kelly DL, Boring RL, et al. SPAR-H step-by-step guidance. Washington (DC): Idaho National Laboratory (INL); 2012. (INL/EXT-10-18533).
   Google Scholar
• Forester J, Kelly D, Kolaczkowski A, et al. Evaluation of human reliability analysis methods against good practices. Washington (DC): Sandia National Laboratories; 2006. (NUREG-1842).
   Google Scholar
• Salas E, Sims DE, Burke CS. Is there a “big five” in teamwork? Small Group Res. 2005;36(5):555–599. doi:10.1177/1046496405277134
   Web of Science ®Google Scholar
• Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. 1^st ed. London: Ashgate; 2008.
   Google Scholar
• Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294–300. doi:10.1097/00003246-199502000-00015
   PubMed Web of Science ®Google Scholar