Human Error and Commercial Aviation Accidents: An Analysis Using the Human Factors Analysis and Classification System

Human Factors Analysis of a Near-Miss Event: Oxygen Supply Failure During Cardiopulmonary Bypass

“…14,15 Prior studies of cardiac surgery have noted that 25-33% of adverse outcomes are preventable (HE). [6][7][8] These error rates in surgery were noted to be 2-4 times higher than those reported by the Institute of Medicine. 1,[16][17][18] With at least 350,000 coronary artery bypass graft procedures annually, it is important that the cardiac care industry inspects itself, understands systemic latent weaknesses and establishes means to prevent morbidity and mortality.…”

“…It has been used in civil aviation, aviation maintenance, air traffic control, railroad and marine safety, and medicine. [5][6][7][8][9][10][11][12][13] HFACS has yet to be applied systematically to cardiac surgery but will be through the following program/s. HE in cardiac surgery is being studied in the Flawless Operative Cardiovascular Unified Systems (FOCUS) initiative through a Learning of Errors through Networked Surveillance technique.…”

Usability of accident and incident reports for evidence-based risk modeling – A case study on ship grounding reports

“…The framework was further developed to also cover other causal factors than human factors, namely environmental factors like machinery failures and meteorological conditions (Wiegmann et al, 2005). The success of the method in detecting the contributing latent and active failures in the accident analysis made the method popular in the field of accident analysis that is vastly used in analysis of civil aviation accidents (Shappell et al, 2007) as well as the accidents in other domains like railroad (Reinach and Viale, 2006) and maritime (Chen and Chou, 2012;Chen et al, 2013). Reinach and Viale (2006) have further developed the method by adding the fifth level, namely ''external factors'', to the initial four levels in order to cover the latent failures that come from outside a particular domain.…”

Frequency of and risk factors for medication errors by pharmacists during order verification in a tertiary care medical center

“…[7][8][9][10][11][12] Human error and the necessity of a safety culture have been heavily studied in other industries such as aviation, aerospace, and oil and gas. 13 For example, in the airline industry, there were approximately 10 million takeoffs and landings each year during the 1990s, with an average of fewer than four crashes per year. 14 The healthcare industry, specifically pharmacy operations, resembles the high-acuity, high-stress work environment seen in aviation.…”