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Taylor-Hyde, Dr Mary Ellen. "Human Resource Strategies for Improving Organizational Performance to Reduce Medical Errors." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/3580.
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Preventable medical errors are the third leading cause of death in the United States. Healthcare leaders must consistently promote the delivery of quality and safe care of patients to reduce unnecessary errors and prevent harm. The purpose of this case study was to explore human resource strategies for improving organizational performance to reduce medical errors. The study included face-to-face interviews with 5 healthcare clinical managers who work within a multifaceted health system in the Midwestern region of the United States. Complex adaptive systems theory was used to frame this study. Interview notes, publicly available documents, and audio recordings were transcribed and analyzed to identify themes regarding strategies used by managers to find effective ways for improvement. Four themes emerged: addressing seminal/never events, ongoing training programs, communication/collaboration, and promoting a culture of safety and quality. Results may directly benefit healthcare managers by facilitating successful strategies to reduce preventable medical errors through education, feedback, innovation, and leadership. Implications for social change for healthcare managers include continued training, building a culture of safety, and using collaborative and communicative efforts while making contributions to the best practices within healthcare organizations to reduce the likelihood of medical errors.
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Baltazar, Ana Rita Duarte Gomes Simões. "Erro humano e erro organizacional nas atividades de manutenção das aeronaves na perspetiva da Grounded Theory : o caso nacional." Doctoral thesis, Instituto Superior de Economia e Gestão, 2020. http://hdl.handle.net/10400.5/20577.
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Doutoramento em GestãoNos últimos anos ocorreram situações que demonstram que os acidentes em organizações de elevada fiabilidade têm consequências catastróficas que precisam de ser contidas ou evitadas. As medidas para a contenção e prevenção do erro estão estabelecidas nesse tipo de organizações, mas focalizam-se em evitar as consequências negativas dos erros, não analisando as consequências positivas dos mesmos (quando existem). A literatura aponta como consequências positivas a aprendizagem, a inovação e a resiliência. O trabalho conclui que de forma conceptual a consequência positiva dos erros é um aumento da Segurança Organizacional através de processos de melhoria associados à Aprendizagem Organizacional. O erro humano não deve ser primariamente entendido como a principal causa dos acidentes, mas antes como uma possível consequência da atividade organizacional. Foi necessário compreender como (How) ocorre e porque (Why) ocorre o erro organizacional; e, ainda, qual a relação entre os diferentes níveis de erro (humano, de equipa e organizacional) e os fatores organizacionais. Esta abordagem transportou o investigador para a necessidade de uma análise aprofundada do conceito de condições/erros latentes. O conhecimento das causas primárias de um incidente/acidente poderá levar a que se criem indicadores que sirvam de alertas em situações futuras e/ou se alterem essas mesmas condições para que se evitem situações idênticas. Verificou-se neste trabalho que cada incidente/acidente, depois de estudado, é uma fonte de informação absolutamente essencial para a melhoria do sistema. No entanto, existem outras fontes que necessitam de ser mais estimuladas, nomeadamente, o reporte de ocorrências e a correspondente análise e partilha de resultados na Organização. A investigação recorre a uma metodologia qualitativa e os resultados aplicam-se apenas à Organização em estudo. O modelo final explica como através do erro de manutenção aeronáutica, na Força Aérea Portuguesa, se aumenta a Segurança Organizacional.
In recent years, situations have occurred which demonstrate that accidents in High Reliability Organizations have catastrophic consequences that need to be restrained or avoided. Measures to contain and prevent errors are established in this type of organizations, but focus on avoiding the negative consequences of errors, thus not analyzing their positive consequences (when they exist). The literature points to positive consequences of learning, innovation and resilience. The study concludes that, in a conceptual way, the positive consequence of the errors is an increase of the Organizational Security through processes of improvement associated with the Organizational Learning. Human error should not be primarily understood as the main cause of accidents, but rather as a possible consequence of organizational activity. It is necessary to understand how and why organizational errors occur; and the relationship between the different levels of error (human, team and organizational) and organizational factors. This approach transported the researcher to the need for an in-depth analysis of the concept of latent conditions / errors. Knowing the root cause of an incident / accident may lead to the creation of indicators that serve as warnings in future situations and / or change the same conditions, so that similar situations are avoided. It was verified in this study that each incident / accident, once studied, is an absolutely essential source of information for the improvement of the system. However, there are other sources that need to be more stimulated, namely the reporting of occurrences and the corresponding analysis and sharing of results in the organization. The research uses a qualitative methodology and the results apply only to the organization being studied. The final model explains how the Organizational Safety is increased, through the aeronautical maintenance error in the Portuguese Air Force.
info:eu-repo/semantics/publishedVersion
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Barbarini, Luiz Henrique Maiorino. "Análise de risco para embarcações com sistemas de alarmes com foco nos fatores humanos e organizacionais." Universidade de São Paulo, 2012. http://www.teses.usp.br/teses/disponiveis/3/3135/tde-19102012-104521/.
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Este trabalho apresenta uma proposta de modelo de análise de risco para embarcações, incorporando em sua formulação a influência das interações entre os sistemas de alarmes e os fatores humanos e organizacionais presentes a bordo. De acordo com estatísticas de sociedades classificadoras, o homem é o maior responsável por acidentes marítimos, e, desta forma, é um dos principais componentes da segurança de uma embarcação. A relevância do elemento humano se dá pelo fato de que ações e decisões humanas estão relacionadas tanto à causa, quanto à prevenção de acidentes. O sistema de alarmes é um equipamento de segurança obrigatório, e com direta participação na dinâmica de um acidente, fornecendo informação para a tomada de decisão das ações por parte da tripulação na resolução do problema. O estudo da interação entre este equipamento e o elemento humano a bordo permite a gestores e armadores elaborar diretrizes para investimentos em sistemas de segurança e políticas que influenciam o desempenho humano, e, portanto, a segurança a bordo. O modelo proposto, inspirado em relatório de acidentes marítimos, tem como ponto de partida uma estrutura sequencial do acidente e leva em consideração uma sucessão usual e simplificada dos eventos ocorridos, iniciando a partir de uma falha no sistema físico. O elemento humano, então, é incorporado à análise de risco através das técnicas de análise de confiabilidade humana, as quais têm como princípio a visão do homem como mais um componente do sistema, ou o liveware interagindo com software e hardware. Sob este ponto de vista, uma abordagem sócio-técnica é aplicada, ou seja, considera-se que um navio é composto não apenas de sua estrutura e máquinas, mas também de toda a tripulação. Com o objetivo de exemplificar passos e hipóteses de uma aplicação do modelo proposto, é apresentada a aplicação ao caso do acidente da embarcação Maersk Doha, ocorrido em outubro de 2006 nos Estados Unidos, cujo relatório de investigação do acidente é de acesso público via Internet, no site da Marine Accident Investigation Branch MAIB.This work presents a risk analysis model for ships, focusing on the scenarios where the crew interacts with the alarm and monitoring system. According to statistics of classification societies, humans are largely responsible for accidents on board and, therefore, are considered a major component of the safety of vessels. The relevance of the human element is given by the fact that human decisions and actions are related to the cause of accidents, either being the direct causative factor of failure or influencing the probability of failure, and the prevention of accidents or mitigation of the consequences. The alarm system is a mandatory component of certified vessels, with direct participation in an accident. It supplies information for the decision making process of the crew, considering their actions to recover the system. The study of the interactions between this automation equipment and the human element on board provides guidelines to managers and owners to invest in proper security systems and policies that influence human behavior, and therefore the safety on board. The model, inspired in accident reports, has as starting point a sequential structure of the accident, and takes into account a typical and simplified sequence of events, starting from a failure in the physical system. The human element is incorporated into the risk analysis through techniques of human reliability analysis, which place man as another component of the system, or the \"liveware\" interacting with software and hardware. From this point of view, a socio-technical approach is applied, considering that a ship is composed of not only its structure and machinery, but also of the entire crew. In order to illustrate the steps and assumptions to be done by an analyst applying the proposed model, the accident of the vessel Maersk Doha, occurred in October of 2006 in the United States, is analyzed. The report on the investigation of this accident is public and accessible via the Internet site of the Marine Accident Investigation Branch MAIB.
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Videira, Rogerio Luiz da Rocha. "Acurácia diagnóstica, análise da decisão e heurísticas relacionadas à decisão clínica intuitiva de usar antagonista de bloqueador neuromuscular." Universidade de São Paulo, 2010. http://www.teses.usp.br/teses/disponiveis/5/5152/tde-01022011-165044/.
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INTRODUÇÃO: A curarização residual está associada a maior risco de morte após anestesia. Erros diagnósticos após o uso de bloqueador neuromuscular (BNM) estão relacionados com prevalência de 65-88% de curarização residual pré-extubação traqueal (CRPE). Esse estudo analisou a decisão clínica intuitiva de usar antagonista de BNM antes da extubação traqueal. MÉTODOS: Após aprovação do Comitê de Ética em Pesquisa, a decisão clínica dos anestesiologistas da nossa instituição foi auditada em 150 pacientes. A participação foi voluntária e anônima. As decisões, como se fossem resultados de um teste diagnóstico, foram comparadas à aceleromiografia, com TOF < 0,9 definido como CRPE. Uma árvore de decisão foi estruturada para comparar as diferentes estratégias e uma pesquisa sequencial (Delphi), realizada entre 108 anestesiologistas, extraiu as heurísticas (regras simplificadoras) mais usadas. RESULTADOS: A prevalência de CRPE foi de 77%. A intuição clínica apresentou sensibilidade de 0,35 (0,23-0,49) e especificidade de 0,80 (0,54- 0,94) para CRPE (P= 0,0001). Em uma escala de 0-10 a utilidade esperada da intuição foi menor do que sempre antagonizar (4,1 + 4,4 vs. 8,4 + 3,0, P< 0,05). As heurísticas mais proeminentes foram O intervalo desde a última dose de BNM foi curto e O padrão respiratório está inadequado, citadas por 73% e 71% dos anestesiologistas, respectivamente. Uma hora após dose única de atracúrio comparada ao rocurônio, 69,3% vs. 47,1% (P= 0,0035) dos anestesiologistas não usam antagonista antes da extubação traqueal. Os anestesiologistas têm a percepção de que a prevalência de curarização residual clinicamente significativa é maior na prática dos seus colegas do que na sua própria prática clínica (razão de chances 7,8 (3,8-16,2) P< 0,0001). CONCLUSÕES: A intuição clínica não deve ser usada para descartar a presença de curarização residual. Sempre usar o antagonista é uma estratégia melhor do que usar a intuição clínica para decidir. Os anestesiologistas tomam a decisão intuitiva baseados em uma previsão da duração dos efeitos do BNM e no julgamento qualitativo da adequação do padrão respiratório do paciente. Eles se consideram mais capacitados para evitar a curarização residual do que os colegas. Demonstram confiança excessiva na própria capacidade de prever a duração de ação do BNM e de descartar intuitivamente a presença de CRPEBACKGROUND: Residual curarization is associated with a higher risk of death after anesthesia. Diagnostic errors after the use of neuromuscular blocking agents (NMBA) are related to 65-88% prevalence of preextubation residual curarization (PERC). This study analyzed the clinical intuitive decision of antagonizing NMBA before tracheal extubation. METHODS: After IRB approval, this clinical decision was audited in 150 patients. Participation in the study was voluntary and anonymous. Decisions, as if a diagnostic test, were compared to acceleromyography, with TOF<0.9 defined as PERC. A decision tree was structured to compare different decision strategies. A sequential survey (Delphi) was conducted among 108 anaesthesiologists to elicit the most frequently used heuristics (rules of thumb). RESULTS: PERC prevalence was 77%. Clinical intuition presented sensitivity of 0.35 (0.23-0.49) and specificity of 0.80 (0.54-0.94) (P=0.0001). In a 0-10 rating scale, expected utility of intuition was lower than always antagonize all patients (4.1 + 4.4 vs. 8.4 + 3.0, P<0.05). The most salient heuristics were Short interval since the last NMBA dose and Breathing pattern is inadequate stated by 73% and 71% of the anesthesiologists, respectively. One hour after a single dose of atracurium compared with rocuronium, 69.3% vs. 47.1% (P= 0.0035) of the anesthesiologists do not use antagonist before tracheal extubation. They perceive that prevalence of clinically significant residual curarization is higher in their colleagues practice than in their own clinical practice (odds ratio 7.8 (3.8- 16.2), P< 0.0001). CONCLUSIONS: Clinical intuition should not be used to rule out residual curarization. Routine antagonism is a better strategy than the use of clinical intuition to make this decision. Clinicians make this intuitive decision based on a forecast of the duration of the effects of NMBA and on a qualitative judgement about the adequacy of the patients breathing pattern. They consider themselves more capable of avoiding residual curarization than their colleagues. They are overconfident in their own capacity to predict NMBA duration and intuitively rule PERC out
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Humanson, Richard, and Patrik Nordeman. "Proactive Crisis Management (PCM) : Perceptions of crisis-awareness and crisis-readiness in organizations in relation with their actual strategic initiatives against industrial crises caused by human errors." Thesis, Blekinge Tekniska Högskola, Institutionen för industriell ekonomi, 2017. http://urn.kb.se/resolve?urn=urn:nbn:se:bth-15519.
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Abstract Purpose: In a competitive and constituently changing global business environment, it is almost impossible for organizations to avoid crises of various types and magnitude. The objective of this study is to display relationships between perception of crisis awareness, crisis readiness and the organizations` actual crisis management initiatives against major industrial crises. This thesis also aims to clarify if the perception of crisis-awareness and crisis-readiness could be affected by other factors that should be in considerations, which in turn could affect the outcomes of crisis-management initiatives and actions in industrial organizations. Methodology: By way of introduction, the problem, which is related to the industrial crises and proactive crisis-management and which also refers to the core topic of the study was formulated and discussed. Research questions about “How the employee’s perception of crisis- awareness and crisis-readiness affects the outcomes of an organization's crisis-management initiatives?” and “How top managements could affect the employee’s perception of crisis- awareness and crisis-readiness positively toward PCM in their organization?” were identified. The covering and important data was collected through scientific literatures and articles and was presented in the theory part. Collected data and empirical findings from the world’s two largest automaker namely, Volkswagen and Toyota, whom has been involved in scandals and crises related to core research of this paper. Empirical findings has been analyzed and finally the answer to the research questions were proposed. Findings: The result of the research indicates that the perception of crisis awareness and crisis readiness in organization have a direct impact on the organizations crisis management initiatives and activities and also there are elements like Corporate Culture, Personnel Education in Crisis Management and Corporate Communication and also other factors, which would affect the perceptions in organizations. Implication: The study suggest that by effective use of elements presented here, organizations could influence employees crisis awareness and crisis readiness positively, thus strengthening the organizations crisis management capacities.
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Al-Shirawi, Ali. "Medical errors: defining the confines of system weaknesses and human errors." Thesis, McGill University, 2011. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=97142.
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Notwithstanding the innovative changes in biotechnology, medical devices and other therapeutics, errors in medicine continue to cause harm to patients. Current definitions of medical error do not reflect the full reality of error causation. Medical error taxonomy is narrowly focused on system weaknesses in health institutions and human error. System weaknesses in licensing and monitoring organizations, health care suppliers, health profession self-regulation and government regulating organizations, conduct by leading health professionals and medical research industry risks, all lead to significant harm that is not recognized in medical error accountability. These players do not fulfill their mandates. Evidence demonstrates negligence, incompetence, unethical conduct and institutional interest and self-interest in the decision-making process. Both the principled approach and institutional ethics (IE) principles are powerful tools to require accountability from stakeholders. The contemporary understanding of medical errors is deficient and unsustainable. It has not contributed to a decrease in errors. Appropriate definitions of the confines of systems weaknesses and human error are required. This thesis outlines a method to perceive medical errors in a broader way, combining the many agents of error/harm into one system, thereby highlighting accountability and paving the way for reform.Malgré les changements innovateurs dans la biotechnologie, l'équipement médical et d'autres approches thérapeutiques, les erreurs dans la pratique de la médecine continuent à provoquer des problèmes médicaux pour un nombre important de patients. Les définitions actuelles d'erreurs médicales ne reflètent pas la réalité complète de la causalité d'erreurs. La taxinomie d'erreurs médicale est aussi strictement concentrée sur les faiblesses du système dans les institutions de santé et l'erreur humaine. Les faiblesses des systèmes qui autorisent et contrôlent les organisations, les fournisseurs de santé publique, les règlements des professions de la santé, les organismes de règlements gouvernemental des professions de la santé et la conduite des professionnels de la santé, et les risques de l'industrie de recherche médicale, tous causent des problèmes importants qui ne sont pas actuellement explicitement reconnu pour leur responsabilité d'erreurs médicales. Ces joueurs ne réalisent pas leurs autorité actuelle. L'évidence démontre de la négligence, de l'incompétence, d'une conduite non étique, d'un intérêt institutionnel et d'un intérêt personnel dans le processus de prise de décision par ces instances. C'est-à-dire, l'approche du principe que les principes de l'éthique institutionnelle sont des instruments puissants pour contraindre la responsabilité de tous les joueurs. La vision contemporaine des erreurs médicales est déficiente et non durable. Une telle vision est déficiente et non supportable. Elle n'a pas contribué à la réduction d'erreurs médicales. Une formulation sur les définitions nécessaires des limitations des systèmes liés à l'être humain est nécessaire. La proposition de cette thèse expose une façon de percevoir les erreurs médicales dans le but de rejoindre les nombreux agents d'erreur et de mal dans un système en mettant ainsi l'emphase sur la responsabilité, et ainsi ouvrant la voie à la réforme.
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Abu, Hawwach Mohammed. "Human errors in industrial operations and maintenance." Thesis, Mälardalens högskola, Innovation och produktrealisering, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:mdh:diva-54794.
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Within maintenance activities and industrial operations, human is subjected to different kind of stresses and situation that could result in mistakes and accidents. The human errors in maintenance and manufacturing are an unexplored latter such that a little focusis invested in this area. The report aims to widen up the understanding of the human error in maintenance and manufacturing area. Aviation and marine operations are the most sectors that are subjected to human errors according tothe literature. There aredifferent types of human error that have effect on quality and overall effectivity. Human reliability models are one method to quantify human errors and usually used for the identification of human errors and HEP calculation. The most common reliability measurement methods are HEART, THERP and SLIM which are used depending on application and industry. As a part of efforts to define differences between those reliability models, literature including different industries is used and itis found that expert judgement influences the success and accuracy of such methods. There are many causes for human errors depending on the application but, communication and procedures followed are the most contributing factors. There is always a probability of existence of human errors as the mistake done by workers are inevitable. Industry 4.0 can help in decreasing human errors through the introduction of operator 4.0 as well as other approaches like training and upgrading organizational standards.
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Khan, Mohammad Ali, and Majid Nasir. "Human Errors and Learnability Evaluation of Authentication System." Thesis, Blekinge Tekniska Högskola, Sektionen för datavetenskap och kommunikation, 2011. http://urn.kb.se/resolve?urn=urn:nbn:se:bth-4054.
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Usability studies are important in today’s context. However, the increased security level of authentication systems is reducing the usability level. Thus, to provide secured but yet usable authentication systems is a challenge for researchers to solve till now. Learnability and human errors are influential factors of the usability of authentication systems. There are not many specific studies on the learnability and human errors concentrating on authentication systems. The authors’ aim of this study is to explore the human errors and the learnability situation of authentication systems to contribute to the development of more usable authentication systems. The authors investigated through observations and interviews to achieve the aim of this study. A minimalist portable test lab was developed in order to conduct the observation process in a controlled environment. At the end of the study, the authors showed the list of identified human errors and learnability issues, and provided recommendations, which the authors believe will help researchers to improve the overall usability of authentication systems. To achieve the aim of the study, the authors started with a systematic literature review to gain knowledge on the state of art. For the user study, a direct investigation, in form of observations and interviews was then applied to gather more data. The collected data was then analyzed and interpreted to identify and assess the human errors and the learnability issues.This study addressed the usability experiences of users by exploring the human errors and the learnability situation of the authentication systems. Authors conducted a case study to explore the situation of human errors and learnability of authentication systems. Observation and interviews were adapted to gather data. Then analysis through SHERPA (to evaluate human errors) and Grossman et al. learnability metric (to evaluate learnability) had been conducted. First, the authors identified the human errors and learnability issues on the authentication systems from user’s perspective, from the gathered raw data. Then further analysis had been conducted on the summary of the data to identify the features of the authentication systems which are affecting the human errors and learnability issues. The authors then compared the two different categories of authentication systems, such as the 1-factor and the multi-factor authentication systems, from the gathered information through analysis. Finally, the authors argued the possible updates of the SHERPA’s human error metric and additional measurable learnability issues comparing to Grossman et al. learnability metrics. The studied authentication systems are not human errors free. The authors identified eight human errors associated with the studied authentication systems and three features of the authentication systems which are influencing the human errors. These errors occurred while the participants in this study took too long time locating the login menu or button or selecting the correct login method, and eventually took too long time to login. Errors also occurred when the participants failed to operate the code generating devices, or failed to retrieve information from errors messages or supporting documents, and/or eventually failed to login. As these human errors are identifiable and predictable through the SHERPA, they can be solved as well. The authors also found the studied authentication systems have learnability issues and identified nine learnability issues associated with them. These issues were identified when very few users could complete the task optimally, or completed without any help from the documentation. Issues were also identified while analyzing the participants’ task completion time after reviewing documentations, operations on code generating devices, and average errors while performing the task. These learnability issues were identified through Grossman et al. learnability metric, and the authors believe more study on the identified learnability issues can improve the learnability of the authentication systems. Overall, the authors believe more studies should be conducted on the identified human errors and learnability issues to improve the overall human errors and learnability situation of the studied authentication systems at presence. Moreover, these issues also should be taken into consideration while developing future authentication systems. The authors believe, in future, the outcome of this study will also help researchers to propose more usable, but yet secured authentication systems for future growth. Finally, authors proposed some potential research ares, which they believe will have important contribution to the current knowledge. In this study, the authors used the SHERPA to identify the human errors. Though the SHERPA (and its metrics) is arguably one of the best methods to evaluate human errors, the authors believe there are scopes of improvements in the SHERPA’s metrics. Human’s perception and knowledge is getting changed, and to meet the challenge, the SHERPA’s human error metrics can be updated as well. Grossman et al. learnability metrics had been used in this study to identify learnability issues. The authors believe improving the current and adding new metrics may identify more learnability issues. Evaluation of learnability issues may have improved if researchers could have agreed upon a single learnability definition. The authors believe more studies should be conducted on the definition of learnability in order to achieve more acceptable definition of the learnability for further research. Finally, more studies should be conducted on the remedial strategies of the identified human errors, and improvement on the identified learnability issues, which the authors believe will help researchers to propose more usable, but yet secured authentication systems for the future growth.
30/1, Shideshwari Lane, Shantinagar, Ramna, Dhaka, Bangladesh, Post Code 1217. Contact: +88017130 16973
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Seastrunk, Chad Stephen. "Algorithm to Systematically Reduce Human Errors in Healthcare." NCSU, 2005. http://www.lib.ncsu.edu/theses/available/etd-12012005-073356/.
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The purpose of the research was to develop an algorithm to permanently reduce human errors in the healthcare industry. The algorithm will be able to be applied to all healthcare organizations and provide a preventative approach to errors. The research involved looking at past methods of error reduction/prevention. Certain methods proved to be useful in generating the algorithm like the Healthcare Failure Modes and Effects Analysis while others like Root Cause Analysis proved to only have limited success. The algorithm takes a three phase approach to reducing errors. Phase One identifies the potential error producing situations. Phase Two uses error proofing principles and known solution directions to generate solutions while Phase Three uses a new method developed called Solution Priority Number to rank and evaluate the solutions. Throughout the algorithm many worksheets have been developed to aid in a team?s progression through the process. Two case studies were performed. The first case study followed a traditional team through the error prevention process while the second case used the algorithm. When comparing the two cases the team using the algorithm finished the process in shorter time, produced more effective failure modes, and generated a richer set of solutions to error proof the process.
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Barroso, Monica Frias da Costa Paz. "Human error and disturbance occurrence in manufacturing systems." Thesis, University of Nottingham, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.342060.
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Wantanakorn, Danai. "Effects of management errors on construction projects." Thesis, University of Nottingham, 2000. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.342472.
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Inoue, Kayoko. "Application of human reliability analysis to nursing errors in hospitals." 京都大学 (Kyoto University), 2005. http://hdl.handle.net/2433/145166.
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Kyoto University (京都大学)0048
新制・課程博士
博士(社会健康医学)
甲第11467号
社医博第4号
新制||社医||1(附属図書館)
23110
UT51-2005-D217
京都大学大学院医学研究科社会健康医学系専攻
(主査)教授 今中 雄一, 教授 佐藤 俊哉, 教授 吉原 博幸
学位規則第4条第1項該当
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Moura, Raphael N. "Learning from accidents : human errors, preventive design and risk mitigation." Thesis, University of Liverpool, 2017. http://livrepository.liverpool.ac.uk/3009336/.
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Recent technological accidents, which resulted in severe material losses, multiple fatalities and environmental damage, were deeply associated with human errors. Direct human actions or flawed decision-making processes have been increasingly tied to devastating consequences, raising major concerns regarding industry's ability to control risks. The most common approach to estimate the probability of human errors and weigh their impact to the overall risk is the application of a suitable Human Reliability Analysis (HRA) technique. However, uncertainties associated with behavioural aspects of humans dealing with advanced technology in complex organisational arrangements turn this type of evaluation into a challenging task to perform, an issue that brings difficulties to ensure sound predictions for human actions when interfacing with complex systems. Consequently, the development of innovative strategies to overcome existing limitations to understand how these sociotechnical systems could fail is of paramount importance, particularly the intricate relationship between humans, technology and organisations. This PhD research project is devoted to approach this multidisciplinary problem in a systematic manner, providing means to recognise and tackle surrounding factors and tendencies that could lead to the manifestation of human errors, improving risk communication and decision making-processes and ultimately increasing confidence in safety studies. The initial part of this thesis comprises a large-scale analysis of human errors identified during major accidents in high-technology systems. Detailed accident accounts were collected from regulators, independent investigation panels, government bodies, insurance companies and industry experts. The raw data is then scrutinised and classified under a common framework, resulting in a novel and comprehensive major-accident dataset, the Multi-attribute Technological Accidents Dataset (MATA-D). The second stage applies advanced data analytic techniques to gain further insight into the conditions leading to the genesis and perpetuation of errors, essentially making use of cluster analysis and classification. The application of different clustering methods reveals common patterns among accidents, and the usage of an artificial neural network approach (self-organising maps) algorithm allows the translation of the multidimensional data into visual representations (2-D maps) of accidents' contributing factors. This stage generates appropriate information to increase the understanding of these sociotechnical systems, to overcome barriers to communicate risk and to enable a wide-ranging 'learning from accidents' process. The final part of the research project builds upon the self-organising maps algorithm output, focusing on a deeper interpretation of specific clusters to disclose strategies to minimise human factors weaknesses and reduce major accidents. An important practical implication suggested by the data analysis is that human errors, in most of the cases, constitute reasonable responses to disruptive transactions between the technology and the organisation, which impact human cognitive functions. Accordingly, the recognition that human errors are mistakenly seen as root-causes of major accidents and the examination of these interaction problems from a new perspective provided an effective way to recognise hazards and tackle major risks, delivering realistic proposals to improve design, decision-making processes and to build trust in safety assessments.
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Dürlich, Luise. "Automatic Recognition and Classification of Translation Errors in Human Translation." Thesis, Uppsala universitet, Institutionen för lingvistik och filologi, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-420289.
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Grading assignments is a time-consuming part of teaching translation. Automatic tools that facilitate this task would allow teachers of professional translation to focus more on other aspects of their job. Within Natural Language Processing, error recognitionhas not been studied for human translation in particular. This thesis is a first attempt at both error recognition and classification with both mono- and bilingual models. BERT– a pre-trained monolingual language model – and NuQE – a model adapted from the field of Quality Estimation for Machine Translation – are trained on a relatively small hand annotated corpus of student translations. Due to the nature of the task, errors are quite rare in relation to correctly translated tokens in the corpus. To account for this,we train the models with both under- and oversampled data. While both models detect errors with moderate success, the NuQE model adapts very poorly to the classification setting. Overall, scores are quite low, which can be attributed to class imbalance and the small amount of training data, as well as some general concerns about the corpus annotations. However, we show that powerful monolingual language models can detect formal, lexical and translational errors with some success and that, depending on the model, simple under- and oversampling approaches can already help a great deal to avoid pure majority class prediction.
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Sambrook, Thomas. "An electrophysiological investigation of reward prediction errors in the human brain." Thesis, University of Plymouth, 2015. http://hdl.handle.net/10026.1/3462.
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Reward prediction errors are quantitative signed terms that express the difference between the value of an obtained outcome and the expected value that was placed on it prior to its receipt. Positive reward prediction errors constitute reward, negative reward prediction errors constitute punishment. Reward prediction errors have been shown to be powerful drivers of reinforcement learning in formal models and there is thus a strong reason to believe they are used in the brain. Isolating such neural signals stands to help elucidate how reinforcement learning is implemented in the brain, and may ultimately shed light on individual differences, psychopathologies of reward such as addiction and depression, and the apparently non-normative behaviour under risk described by behavioural economics. In the present thesis, I used the event related potential technique to isolate and study electrophysiological components whose behaviour resembled reward prediction errors. I demonstrated that a candidate component, “feedback related negativity”, occurring 250 to 350 ms after receipt of reward or punishment, showed such behaviour. A meta-analysis of the existing literature on this component, using a novel technique of “great grand averaging”, supported this view. The component showed marked asymmetries however, being more responsive to reward than punishment and more responsive to appetitive rather than aversive outcomes. I also used novel data-driven techniques to examine activity outside the temporal interval associated with the feedback related negativity. This revealed a later component responding solely to punishments incurred in a Pavlovian learning task. It also revealed numerous salience-encoding components which were sensitive to a prediction error’s size but not its sign.
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Staab, Ryan. "Recognizing specific errors in human physical exercise performance with Microsoft Kinect." DigitalCommons@CalPoly, 2014. https://digitalcommons.calpoly.edu/theses/1246.
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The automatic assessment of human physical activity performance is useful for a number of beneficial systems including in-home rehabilitation monitoring systems and Reactive Virtual Trainers (RVTs). RVTs have the potential to replace expensive personal trainers to promote healthy activity and help teach correct form to prevent injury. Additionally, unobtrusive sensor technologies for human tracking, especially those that incorporate depth sensing such as Microsoft Kinect, have become effective, affordable, and commonplace.
The work of this thesis contributes towards the development of RVT systems by using RGB-D and tracked skeletal data collected with Microsoft Kinect to assess human performance of physical exercises. I collected data from eight volunteers performing three exercises: jumping jacks, arm circles, and arm curls. I labeled each exercise repetition as either correct or one or more of a select number of predefined erroneous forms. I trained a statistical model using the labeled samples and developed a system that recognizes specific structural and temporal errors in a test set of unlabeled samples. I obtained classification accuracies for multiple implementations and assess the effectiveness of the use of various features of the skeletal data as well as various prediction models.
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Nelson, Tess. ""To err is human" the effects of anxiety and contextual emotion on error-related negativity /." Diss., Connect to the thesis, 2007. http://hdl.handle.net/10066/1016.
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Lichliter, Ann. "Organizational commitment of Nonprofit Human Service assistants." Thesis, Saint Mary's University of Minnesota, 2016. http://pqdtopen.proquest.com/#viewpdf?dispub=3745603.
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Nonprofit Human service assistants provide much of the direct care for the most vulnerable and disenfranchised populations (Annie E. Casey Foundation, 2003; Cleary et al., 2006.) Their high turnover rates compromise service quality and increase nonprofit costs (Annie E. Casey Foundation, 2003; Baumeister & Zaharia, 1987; Durlak & Roth, 1983; Mor Barak, Nissly, & Levin, 2001; Rutowski, Guiler, & Schimmel, 2009). To ensure client services are effective, nonprofit leaders need to identify strategies to enhance human service assistant’s organizational commitment. This qualitative study explored how human service assistants perceived their organizational commitment and the experiences that impacted their organizational commitment. From the interviews with 21 human service assistants, a grounded theory emerged illustrating the factors that foster organizational commitment. Human service assistants arrived at their agency with experiences, characteristics, and/or personal circumstances that may have influenced their commitment. Once employed, the nonprofit environment provided experiences that fostered organizational commitment. The culmination of these experiences resulted in participants feeling valued by the organization or I matter. Feeling they mattered was the core condition for organizational commitment.
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Chellino, Susan N. "Improving organizational results through human performance technology." Thesis, Boston University, 1988. https://hdl.handle.net/2144/38018.
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Thesis (Ed.D.)--Boston UniversityPLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you.
This study investigated the effects of a performance improvement program on operational results in a business setting. The purpose of the study was to determine if the intervention influenced results the corporation used to measure its success. The intervention involved setting goals, which would its success. The intervention involved setgiving feedback and developing remediation overcome difficulties if goals were not achieved. Goal-setting and feedback were done at regularly scheduled intervals. Two work groups within the organization were studied: one which applied the program and one which did not. The effect of the intervention was evaluated using a 2 x 2 design. Two factors represented the pre-program versus post-program time periods; the other two factors represented the experimental conditions: treatment and control. The effect of the program was quantified in terms of five measures of organizational success. These measures were: attendance, safety, quality, maintenance efficiency and installation efficiency.
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Montague, Diane M. "Medication errors in hospitals : to ERR is human, to report is divine." Honors in the Major Thesis, University of Central Florida, 2001. http://digital.library.ucf.edu/cdm/ref/collection/ETH/id/235.
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This item is only available in print in the UCF Libraries. If this is your Honors Thesis, you can help us make it available online for use by researchers around the world by following the instructions on the distribution consent form at http://library.ucf.edu/Systems/DigitalInitiatives/DigitalCollections/InternetDistributionConsentAgreementForm.pdf You may also contact the project coordinator, Kerri Bottorff, at kerri.bottorff@ucf.edu for more information.Bachelors
Health and Public Affairs
Legal Studies
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Forrest, Tammy J. "Memory errors in elementary school children." Diss., Full text available online (restricted access), 2002. http://images.lib.monash.edu.au/ts/theses/Forrest.pdf.
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Lewis, Martin David. "Human lysosomal sulphate transport." Title page, contents and abstract only, 2001. http://web4.library.adelaide.edu.au/theses/09PH/09phl6752.pdf.
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Addendum inserted at back Includes bibliographical references (leaves 266-287). 1. Introduction -- 2. Materials and general methods -- 3. Characterisation and partial purification of the lysosomal sulphate transporter -- 4. Identification of proteins involved in lysosomal sulphate transport -- 5. The relationship between a sulphate anion transporter family and the lysosomal sulphate transporter -- 6. Investigation of sulphate transport in human skin fibroblasts -- 7. Concluding remarks
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Boright, Andrew Pepler. "Prolidase deficiency : studies in human dermal fibroblasts." Thesis, McGill University, 1988. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=75956.
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Prolidase deficiency (MIM 26413), an autosomal recessive phenotype, is caused by rare alleles at a locus on chromosome 19cent.-q13.2. The clinical phenotype is pleiotropic (affecting skin, brain, etc.) and of variable expressivity (benign to early death). I established skin fibroblast cultures from 6 homozygous probands and 6 obligate heterozygotes, purified prolidase (E.C. 3.4.13.9, a homodimer) from normal human fibroblasts, raised a monospecific rabbit antiserum to the subunit, and studied its biosynthesis. Pulse-chase immunoprecipitation experiments showed that the subunit is synthesized in the cytosol as a 58 KDa. polypeptide and not processed further. Homozygous prolidase-deficient cell strains expressed 3 classes of mutant alleles which by complementation analysis mapped to one locus. The alleles were designated CRM$-$ (nul), CRM+ activity/size variant, and CRM+ activity variant. Heterozygotes carrying CRM$-$ alleles have heat stable prolidase (50$ sp circ$C, 1hr); heterozygotes carrying CRM+ variant alleles have heat labile enzyme. The finding implies that variant CRM+ allele(s) can confer negative allelic complementation on the dimeric enzyme (dominant relative phenotype). CRM$-$ homozygous cells contain varying amounts of an alternative imidodipeptidase-like activity. The variant prolidase allele (major gene) and amount of alternative "prolidase" activity (modifier gene) are apparently both determinants of the associated clinical phenotype in prolidase deficiency. I obtained and sequenced a tryptic peptide from human kidney prolidase for synthesis of oligonucleotide probes in the future.
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Dolenga, Michael Peter. "Metabolic studies of prolidase deficiency in cultured human fibroblasts." Thesis, McGill University, 1991. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=61190.
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Prolidase deficiency (McKusick 26413) is a rare autosomal recessive disorder characterized by iminodipeptiduria, skin lesions and mental retardation. The enzyme prolidase hydrolyzes dipeptides containing C-terminal proline or hydroxyproline.The results presented here indicate that prolidase plays a major role in the recycling of dipeptide bound proline. Control fibroblasts were able to use iminodipeptides in lieu of proline to sustain normal growth and protein synthesis whereas prolidase deficient cells were not.
Iminodipeptides added to the media of control and mutant cells showed no adverse effects on protein synthesis or cell growth. These results are consistent with a mechanism of biochemical pathology in which proline deprivation caused by the enzyme deficit is the cause of damage to skin cells.
Prolidase regulation by product and substrate was studied. A two fold decrease of prolidase activity was observed in fibroblasts grown in excess proline. However, cells grown in medium in which iminodipeptides replaced proline showed no significant difference in prolidase activity.
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Farooqi, Aaisha Tasneem. "Methods for the investigation of work and human errors in rail engineering contexts." Thesis, University of Nottingham, 2016. http://eprints.nottingham.ac.uk/32114/.
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It is important to study accidents and their underlying causes, in order to generate recommendations for improving system safety. A range of methods have been developed in various industries, to understand how accidents have occurred, as well as identify potential human errors in systems. Theories of accident causation, and the development of safety models and methods have evolved over the last few decades. However, the majority of accident analysis methods fail to account for the increasing complexity of socio-technical systems (Hollnagel, 2004 and Lindberg et al. 2010). Much of the previous research has taken a safety I perspective, which considers successful performance as reducing the number of adverse outcomes to as low as possible (Hollnagel, 2014). According to Hollnagel (2014) however, it is important to understand how operators actually carry out work (‘work-as-done’), rather than as it should be carried out (‘work-as-imagined’), to understand how normal variabilities and flexibilities in performance contribute towards both successful and unsuccessful performance. Understanding how work is normally carried out is essential for understanding how it can go wrong. This includes understanding how success is obtained, for example how people adjust their performance in the face of changing conditions and demands, and limited resources (such as time and information). Although variability and flexibility in performance are prerequisites for success and productivity, these can also explain why things can go wrong (Hollnagel, 2014). Understanding normal work (or ‘work-as-done’) is the basis of the safety II perspective, which views safety as increasing the number of things that go right. So far however, there seems to be little application of this safety II perspective in the rail industry. Research in this thesis addresses this gap, by examining whether understanding normal performance in rail engineering contexts contributes towards identifying how incidents occur, and measures for improving safety, compared to the use of existing methods. A range of different methods were used to address the aims of this thesis. Rail incident reports were analysed to understand sources of human errors in rail contexts. Observations were also conducted of operators carrying out work, to understand the opportunities for human errors associated with rail engineering processes. To understand cognitive demands and strategies associated with normal work, a cognitive task analysis was carried out. FRAM (Functional Resonance Analysis Method) (Hollnagel, 2012) wasalso used to determine how incidents may develop, and whether everyday performance can contribute towards successful and unsuccessful performance. Participants in semi-structured interviews and workshops were asked to identify strengths and limitations of various human reliability assessment methods, and offer opinions on their practical applicability. Benefits of understanding normal work included a greater understanding of how human errors can occur (by identifying cognitive demands that contribute towards the occurrence of different error types), and how cognitive strategies can reduce human errors and contribute towards acceptable performance. It was demonstrated how variabilities and flexibilities in performance can contribute towards successful and productive performance, as well as explain why things can go wrong (supporting Hollnagel, 2014). This is especially important to consider, since human errors were not easily identified from rail incident reports and observations of operators carrying out work. System safety can therefore be improved by increasing things that can go right, rather than just decreasing the things that can go wrong (Hollnagel, 2014). Participants in a workshop, however, identified that FRAM may be time consuming to apply, especially for more complex systems. Further research is recommended for the development of a toolkit, from which both practitioners and researchers can choose from a range of different methods. To further understand factors affecting acceptable performance, it is recommended that further data are collected to determine whether varying levels of cognitive demands affect performance, and whether these influence the implementation of cognitive strategies.
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Xanthopoulou, L. "Molecular and cytogenetic investigation of chromosomal errors in human preimplantation development : possible causes." Thesis, University College London (University of London), 2013. http://discovery.ucl.ac.uk/1383595/.
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Chromosome abnormality is the leading cause of pregnancy loss, mental retardation and IVF failure in humans; it is a significant contributor to infertility and other disorders. Despite ~20 years of molecular cytogenetics in human embryos, many questions remain with respect to the origin, role, frequency and different causes of chromosomal errors at this stage. This thesis focuses on structural chromosomal abnormalities, chromosome breakage, binucleate cells, microsatellite instability and SYCP3 mutations. Carriers of structural abnormalities are at high risk of unfavourable meiotic segregation and production of unbalanced gametes/embryos. 396 biopsied blastomeres and 221 untransferred embryos from preimplantation genetic diagnosis (PGD) cycles were analysed by fluorescence in situ hybridisation (FISH). The aims were 1) to study the meiotic and mitotic behaviour in 19 reciprocal translocation carriers, and 2) in 2 intrachromosomal insertion carriers; 3) to investigate the overall level of chromosome breakage, meiotic aneuploidy, mosaicism and chromosome breakage, and 4) to assess whether advanced maternal age adversely affected PGD outcome in 59 PGD reciprocal translocations cycles. The frequency and chromosomal complement of biopsied binucleate cells (a common PGD complication) from 66 PGD and 151 PGS cycles were analysed to investigate the nature and origin of binucleate cells (aim 5). Proposed mechanisms of binucleation indicated that such cells should mostly be tetraploid; in this study however the majority appeared diploid. Microsatellite instability (MSI) has been previously associated with spontaneous abortions, thus DNA from 53 PGS embryos and their parents were analysed using ten polymorphic markers revealing an MSI frequency of 22%. SYCP3 occurs in the synaptonemal complex and is involved in chromosome synapsis. Previous reports associated SYCP3 mutations with recurrent pregnancy loss and azoospermia. DNA from 102 individuals undergoing PGS and 18 females with recurrent miscarriages were tested to investigate whether SYCP3 mutations are associated with infertility (aim 7). No mutations were identified.
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Cunningham, Thomas Raymond. "A comprehensive approach to preventing errors in a hospital setting: Organizational behavior management and patient safety." Diss., Virginia Tech, 2009. http://hdl.handle.net/10919/26279.
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Estimates of the number of U.S. deaths each year resulting from medical errors range from 44,000 (Institute of Medicine, 1999) to 195,000 (HealthGrades, 2004). Additionally, instances of medical harm are estimated to occur at a rate of approximately 15 million per year in the U.S., or about 40,000 per day (Institute for Healthcare Improvement, 2007).
Although several organizational behavior management (OBM) intervention techniques have been used to improve particular behaviors related to patient safety, there remains a lack of patient-safety-focused behavioral interventions among healthcare workers. OBM interventions are often applied to needs already identified within an organization, and the means by which these needs are determined vary across applications. The current research addresses gaps in the literature by applying a broad needs-assessment methodology to identify patient-safety intervention targets in a hospital and then translating OBM intervention techniques to identify and improve the prevention potential of responses to reported medical errors.
A content analysis of 17 months of descriptions of follow-up actions to error reports for nine types of the most-frequently-occurring errors was conducted. Follow-up actions were coded according to a taxonomy of behavioral intervention components, with accompanying prevention scores based on criteria developed by Geller et al. (1990). Two error types were selected for intervention; based on the highest frequency of reporting and lowest average follow-up prevention score. Over a three-month intervention period, managers were instructed to respond to these two error types with active communication, group feedback, and positive reinforcement strategies.
Results indicate improved prevention potential as a consequence of improved corrective action for targeted errors. Future implications for identifying and classifying responses to medical error are discussed.Ph. D.
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Ottolini, Christian Simon. "Chromosome segregation and recombination in human meiosis : clinical applications and insight into disjunction errors." Thesis, University of Kent, 2015. https://kar.kent.ac.uk/53977/.
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Chromosome copy number errors (or aneuploidy) of gametes and embryos occurs in humans more frequently than in any other studied species, with a spectrum of manifestations from implantation failure to affected live births. It is predominantly problem arising in maternal meiosis with at least 20% of oocytes being aneuploid, a proportion that increases dramatically with advancing maternal age. Currently the only intervention to reduce the chances of transmitting aneuploidy is by invasive embryo biopsy procedures in high-risk groups (mainly patients with advanced maternal age) undergoing in-vitro fertilisation. Despite the severity of this problem, aneuploidy of the human preimplantation embryo is relatively poorly understood. With this in mind the purpose of this thesis is to explore the premise underpinning the use of preimplantation genetic screening (PGS) in human embryos and investigate its clinical applications and current methodologies. A series of published works demonstrate what I believe to be a significant contribution to the development of applications for studying human preimplantation aneuploidy, also providing insight into its origins and mechanisms at the earliest stages of human development. Specifically, I present a novel standard set of protocols as a general reference work from practitioners in the fields of embryo biopsy and array comparative genomic hybridisation (CGH - the current ‘gold standard’ for preimplantation aneuploidy screening). I present a summary of work encapsulated in three published clinical papers using a linkage based analysis of Single Nucleotide Polymorphism (SNP) karyotypes (Karyomapping). Karyomapping was designed as a near-universal approach for the simultaneous detection of chromosomal and monogenic disorders in a PGS setting and these results demonstrate the utility of the technique in three separate scenarios. In order to study the underlying mechanisms of female meiosis I present my findings on the use of a calcium ionophore to activate human oocytes artificially. An algorithm based on Karyomapping (termed MeioMapping) is demonstrated for the first time specifically to investigate human female meiosis. By recovering all three products of human female meiosis (oocyte, and both polar biopsies – herein termed “Trios”) using calcium ionophore, I present a novel protocol (commissioned by Nature Protocols) to allow exploration of the full extent of meiotic chromosome recombination and segregation that occurs in the female germline. Finally I present a published set of experiments using this protocol to provide new insight into meiotic segregation patterns and recombination in human oocytes. This work uncovers a previously undescribed pattern of meiotic segregation (termed Reverse Segregation), providing an association between recombination rates and chromosome mis-segregation (aneuploidy). This work demonstrates that there is selection for higher recombination rates in the female germline and that there is a role for meiotic drive for recombinant chromatids at meiosis II in human female meiosis. The work presented in this thesis provides deeper understanding of meiotically derived maternal aneuploidy and recombination. More importantly it provides a vehicle within an ethical framework to continue to expand our knowledge and uncover new insights into the basis of meiotic errors that may aid future reproductive therapies.
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Laka-Mathebula, Mmakgomo Roseline. "Modelling the relationship between organizational commitment, leadership style, human resources management practices and organizational trust." Pretoria : [s.n.], 2004. http://upetd.up.ac.za/thesis/available/etd-07062004-112817.
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SOUSA, HENRIQUE PRADO DE SA. "ANALYZING THE HUMAN RESOURCE STRATEGIC ALIGNMENT THROUGH ORGANIZATIONAL MODELS." PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO, 2017. http://www.maxwell.vrac.puc-rio.br/Busca_etds.php?strSecao=resultado&nrSeq=32725@1.
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PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIROCOORDENAÇÃO DE APERFEIÇOAMENTO DO PESSOAL DE ENSINO SUPERIOR
CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO
PROGRAMA DE EXCELENCIA ACADEMICA
Modelos organizacionais são excelentes insumos para a engenharia de requisitos, uma vez que eles são ricos em detalhes sobre o sistema de informação, permitindo a comunicação, entendimento, avaliação do domínio, e a elicitação da informação para a definição de requisitos de software. Dentro do contexto da administração organizacional, estes modelos são usados em uma variedade de propósitos, incluindo o alinhamento organizacional, o qual é um dos maiores desafios das companhias em ambientes de alta competitividade. O alinhamento organizacional torna explicita as relações entre a camada operacional e de objetivos, o que deve ser representado através de modelos organizacionais para ampliar as possibilidades de avaliação, mensuração e melhoria. No contexto de sistemas de software, é importante o uso de modelos com alta qualidade e aderência aos objetivos organizacionais. Para se alcançar um nível satisfatório de alinhamento, somente a projeção de processos bem definidos não é suficiente. Também é necessário o alinhamento estratégico de diversas perspectivas da organização, por exemplo, financeira, planejamento, tecnologia e recursos humanos. Entretanto, quando se trata de alinhamento estratégico, as linguagens de modelagem organizacional não abordam diversos aspectos. Esta tese busca expandir a capacidade da modelagem organizacional, inserindo recursos que ajudam a análise do alinhamento estratégico. Em especial, a perspectiva de Recursos Humanos é abordada, a qual consideramos uma das mais relevantes para o alinhamento organizacional devido a sua posição vital na execução dos processos organizacionais.
Organizational models are excellent inputs for requirement engineering, since they carry a huge amount of detail about information systems, allowing the communication, understanding, domain evaluation, and the information elicitation to the definition of software requirements. Inside the organizational administration context, these models are used for a variety of purposes, including organizational alignment, which is a major challenge for companies in a highly competitive environment. Organizational alignment makes explicit the relationship between the operational and objective layers, what must be represented in organizational models to increase the possibilities of evaluation, measurement and improvement. In the context of software systems, it is important to use models with higher quality and adherence to the organizational objectives. To achieve satisfactory level of alignment, only the designing of well-defined processes is not enough. It is also necessary to strategically align diverse perspectives of the organization, for example, budget, planning, technology, and human resources. However, when it comes to strategic alignment, organizational modeling languages do not address several aspects. This thesis seeks to expand the capacity of organizational modeling, inserting resources that help the strategic alignment analysis. Especially the Human Resources perspective will be approached, which we consider one of the most relevant to organizational alignment, due to its vital position in the execution of organizational processes.
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Kuczmanski, Jacob John. "The Effects of the Planning Fallacy and Organizational Error Management Culture onOccupational Self-Efficacy." Xavier University / OhioLINK, 2016. http://rave.ohiolink.edu/etdc/view?acc_num=xavier1458508013.
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Wright, Justin. "Human Aggression and Sports Media Violence." TopSCHOLAR®, 2006. http://digitalcommons.wku.edu/theses/985.
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The present study was designed to gain more perspective on human aggression and how sports media violence affects aggression levels. Anderson (1997) defined aggression as behavior that is intended to harm others or one's self. Anderson (2001) defined media violence as a portrayal of intentional harmful behavior directed at another person or the self. To define sports aggression, the definition of aggression must be manipulated slightly. The definition should be changed to a form of behavior intended to injure, whether or not an actual injury occurs, directed at an opposing team or opposing player to gain an advantage during the progression of play. An example of this would be trying to hurt a key player of the opposing team so that this player can no longer perform at a level expected of him by others. This definition does not include aggressive behavior toward people watching the game or officials during the game. It only pertains to playeron-player aggression and those actions taken that are allowed with in the rules of the game. Sports media violence does not include players and fan interaction, two fans fighting, or violent acts between players and officials. Many studies have been completed looking at human aggression levels and how certain media types affect aggression levels. In a study completed in 2001, it was shown that viewing violent movies can increase aggression levels in participants (Bushman & Anderson, 2001). Another study completed by Phillips (1986), examined and compared the homicide rates in America the day after a major boxing match had occurred to the average homicide rate. His findings suggest that a relationship between viewing boxing and homicide rates exists. The more people who viewed the fight the night before, the higher the homicide rates were in America the next day. The present study is attempting to look specifically at the effects of sports violence in the media on aggression levels of its viewers. Participants completed a Buss-Perry Aggression Scale before the experiment began to assess their pre-experiment aggression levels. Then the participants were randomly assigned to view one of the video groups: non-violent sport, violent sport, nonviolent movie, or violent movie. The participants were randomly assigned to conditions based on the times at which they signed up to complete the study. They next watched a five-minute video clip. The content of each video varied by the conditions of the experiment, for example, nonviolent sport, violent sport, nonviolent movie, or violent movie. After watching the video, each group was given the Word Completion Task to assess post-video aggression levels. Results indicated that after viewing violent forms of video material, sports and non-sports, aggression levels increased in participants significantly. But when participants viewed non-aggressive material their aggression levels did not increase significantly. Therefore, exposure to violent sports has the potential to increase levels of aggression following such exposure, just as exposure to violent movies and television shows increases aggression. However, there are other factors that play a role in the development of aggressive behavior.
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King, Tracey L. "The impact of a nurse-driven evidence-based discharge planning protocol on organizational efficiency and patient satisfaction in patients with cardiac implants." Orlando, Fla. : University of Central Florida, 2008. http://purl.fcla.edu/fcla/etd/CFE0002188.
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Wallström, Peter. "Evaluation of forecasting techniques and forecast errors : with focus on intermittent demand." Licentiate thesis, Luleå tekniska universitet, Industriell Ekonomi, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:ltu:diva-17514.
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To decide in advance the amount of resources that is required next week or next month can be both a complicated and hazardous task depending on the situation, despite the known time frame when the resources are needed. Intermittent demand, or slow-moving demand, that is when there are time periods without demand and then suddenly a time period with demand, becomes even more difficult to forecast. If the demand is underestimated it will lead to lost sales and therefore lost revenues. If the demand is overestimated, in the best case the stock is increased or in worst case, the items lie unsold until they become obsolete. The items with intermittent demand can have a value of up to 60% of the total stock value for all items.This thesis addresses the topic of forecasting intermittent demand and how to measure the accuracy of the chosen forecast method or methods. Four forecasting methods are tested on almost 18 months of empirical demand data from a manufacturing company. The tested forecasting method are single exponential smoothing, Croston and two modification of the Croston method, one by Syntetos and Boylan the other by Segerstedt (modified Croston). Four start values and eight smoothing constants are tested. The methods are evaluated with different accuracy measures; variance (MSE and MAD), bias (CFE, the maximum and minimum value of CFE) and sMAPE. In addition with a new complementary measure of bias; Periods in Stock (PIS), PIS considers the time aspect, when the forecast error occurred not just the error size. Also two variants of MAD and MSE are tested. To improve the evaluation of the bias measures, the percentages of demand occasions that can not be fulfilled are used. The relationship between the different errors for a certain method is examined with principal component analysis (PCA). The errors are also examined with logistic regression to find out if a certain forecasting method is favoured by certain accuracy measures. The logistic regression is based on descriptive statistics for time series plus the mean absolute change that considers the sequence of the time series as well as the variation. Ranking and error quotients between different methods are other applied methods. The results of the research both confirm and contradict earlier findings. Among the confirming research results are the bias among the different methods. Croston and Modified Croston are overestimating the demand, Syntetos and Boylan's Croston variant has a tendency to underestimate the demand. Single exponential smoothing is relatively biasfree when low smoothing constants are concerned. The contradictive results are that CFE is not a suitable measure of bias at least when the number of forecasting periods is limited. The value of CFE can indicate a nonbiased forecast when both PIS and the percentage of unmet demands indicate a biased forecast. PIS is also less sensitive to transient demand events that can distort CFE. PIS is recommended as a bias measure for limited time series, especially considering intermittent demand, along with the percentage of unmet demand. Another result is that MAD is not reliable since the method in certain circumstances favours methods that underestimate the demand.Att på förhand bestämma vilken mängd resurser som krävs nästa vecka eller nästa månad kan vara både en komplicerat och riskfylld uppgift beroende av situation, trots att man känner till när resurserna behövs. Intermittent efterfrågan, eller lågrörlig efterfrågan, är när många perioder saknar efterfrågan och plötsligt sker en efterfrågan en period. Detta gör det svårare att prognostisera. Om efterfrågan underskattas kommer det att leda till förlorad försäljning och därmed förlorade intäkter. Om efterfrågan är överskattad kommer det i bästa fall att bara leda till ökat lager eller, i värsta fall, leda till osålda produkter och till slut inkurans. Artiklar med intermittent efterfrågan kan utgöra upp till 60 % av det totala lagervärdet för samtliga artiklar.Denna uppsats avhandlar prognoser av intermittent efterfrågan samt hur prognosfelen ska mätas för den valda eller de valda prognosmetoderna. Fyra prognosmetoder utvärderas med nästan 18 månaders empirisk efterfrågedata från ett tillverkande företag. De utvärderade metoderna är exponentiell utjämning, Croston och två modifierade varianter av Croston; Syntetos och Boylans metod samt modifierad Croston av Segerstedt. Fyra olika startvärden och åtta utjämningskonstanter används. Prognosmetoderna utvärderas med olika typer av prognosfel; varians (MSE och MAD), bias (CFE samt max- och minvärde av CFE) och sMAPE. Vidare sker utvärdering med ett komplimenterande mått för bias, Lagerperioder (Periods in Stock, PIS). PIS tar tidsaspekten i beaktande och inte bara storleken på prognosfelen. Dessutom undersöks två varianter av MAD och MSE. För att förbättra utvärderingen av biasmåtten undersöks procentantalet av de efterfrågetillfällen som en prognosmetod inte kan uppfylla.Förhållandet mellan de olika prognosfelen undersöks med hjälp av principal component analysis (PCA). Prognosfelen undersöks även med binär logistisk regression för att utröna huruvida vissa prognosmetoder gynnas av vissa prognosfel. Den logistiska regressionen baseras på deskriptiv statistik för tidsserierna samt medelabsolutförändringen som tar ordningen för tidserien i beaktande såväl som variationen. Rankning och kvoter mellan olika prognosfel från olika metoder är andra tillämpade metoder. Resultatet av forskningen både bekräftar och motsäger tidigare forskning. Bland de bekräftande resultaten är den bias olika prognosmetoder har. Croston och modifierad Croston överskattar efterfrågan, Syntetos och Boylans metod underskattar efterfrågan. Exponentiell utjämning är förhållandevis fri från bias när utjämningskonstanterna har låga värden. De avvikande resultaten är att CFE inte är lämpligt att använda när antal prognosperioder är begränsat. Värdet för CFE kan indikera att prognosen är fri från bias när både PIS och procentandelen icke mött efterfrågan. PIS är dessutom mindre känslig för transienta efterfrågehändelser som kan förvränga CFE. PIS rekommenderas som ett biasmått när tidsserien är ändlig, särskilt när det gäller intermittent efterfrågan, tillsammans med måttet procentandelen icke mött efterfrågan. Andra resultat är att MAD inte är pålitlig eftersom måttet, under vissa förhållanden, gynnar prognosmetoder som underskattar efterfrågan
Godkänd; 2009; 20090520 (petwal); LICENTIATSEMINARIUM Ämnesområde: Industriell logistik/Industrial Logistics Examinator: Professor Anders Segerstedt, Luleå tekniska universitet Tid: Onsdag den 17 juni 2009 kl 10.00 Plats: A 3120, Luleå tekniska universitet
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Wollenbecker, Joan M. "Using MTWS for human-in-the-loop C2 organizational experiments." Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 1999. http://handle.dtic.mil/100.2/ADA369243.
Full textAbstract:
Thesis (M.S. in Systems Technology (Command, Control, Computers, Communications, and Intelligence)) Naval Postgraduate School, September 1999."September 1999". Thesis advisors(s): William G. Kemple, Gary R. Porter. Cover title: Using ... experiements. Includes bibliographical references (p. 451). Also Available online.
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Stringfellow, Margaret Virgina. "Accident analysis and hazard analysis for human and organizational factors." Thesis, Massachusetts Institute of Technology, 2010. http://hdl.handle.net/1721.1/63224.
Full textAbstract:
Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Aeronautics and Astronautics, February 2011."October 2010." Cataloged from PDF version of thesis.
Includes bibliographical references (p. 275-283).
Pressures and incentives to operate complex socio-technical aerospace systems in a high-risk state are ever present. Without consideration of the role humans and organizations play in system safety during the development of these systems, accidents will occur. Safe design of the "socio" parts of the sociotechnical system is challenging. Even if the system, including the human and organizational aspects of the system, are designed to be safe for anticipated system needs and operating environments, without consideration of pressures for increased performance and efficiency and shifting system goals, the system will migrate to a high-risk operating regime and safety can be compromised. Accident analysis is conducted to discover the reasons why an accident occurred and to prevent future accidents. Safety professionals have attributed 70-80% of aviation accidents to human error. Investigators have long known that the human and organizational aspects of systems are key contributors to accidents, yet they lack a rigorous approach for analyzing their impacts. Many safety engineers strive for blame-free reports that will foster reflection and learning from the accident, but struggle with methods that require direct technical causality, do not consider systemic factors, and seem to leave individuals looking culpable. An accident analysis method is needed that will guide the work, aid in the analysis of the role of human and organizations in accidents and promote blame-free accounting of accidents that will support learning from the events. Current hazard analysis methods, adapted from traditional accident models, are not able to evaluate the potential for risk migration, or comprehensively identify accident scenarios involving humans and organizations. Thus, system engineers are not able to design systems that prevent loss events related to human error or organizational factors. State of the art methods for human and organization hazard analysis are, at best, elaborate event-based classification schemes for potential errors. Current human and organization hazard analysis methods are not suitable for use as part of the system engineering process. Systems must be analyzed with methods that identify all human and organization related hazards during the design process, so that this information can be used to change the design so that human error and organization errors do not occur. Errors must be more than classified and categorized, errors must be prevented in design. A new type of hazard analysis method that identifies hazardous scenarios involving humans and organizations is needed for both systems in conception and those already in the field. This thesis contains novel new approaches to accident analysis and hazard analysis. Both methods are based on principles found in the Human Factors, Organizational Safety and System Safety literature. It is hoped that the accident analysis method should aid engineers in understanding how human actions and decisions are connected to the accident and aid in the development of blame-free reports that encourage learning from accidents. The goal for the hazard analysis method is that it will be useful in: 1) designing systems to be safe; 2) diagnosing policies or pressures and identifying design flaws that contribute to high-risk operations; 3) identifying designs that are resistant to pressures that increase risk; and 4) allowing system decision-makers to predict how proposed or current policies will affect safety. To assess the accident analysis method, a comparison with state of the art methods is conducted. To demonstrate the feasibility of the method applied to hazard analysis; it is applied to several systems in various domains.
by Margaret V. Stringfellow.
Ph.D.
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Hansson, Ann-Sophie. "Determinants of Individual and Organizational Health in Human Service Professions." Doctoral thesis, Uppsala : Acta Universitatis Upsaliensis : Univ.-bibl. [distributör], 2008. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-8715.
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Park, Yoonhee. "The relationships among investment in workplace learning, organizational perspective on human resource development, organizational outcomes of workplace learning, and organizational performance using the Korea 2005 and 2007 human capital corporate panel surveys." Columbus, Ohio : Ohio State University, 2009. http://rave.ohiolink.edu/etdc/view.cgi?acc%5Fnum=osu1245431229.
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Park, Yoonhee. "The Relationships Among Investment in Workplace Learning, Organizational Perspective on Human Resource Development, Organizational Outcomes of Workplace Learning, and Organizational Performance Using the Korea 2005 and 2007 Human Capital Corporate Panel S." The Ohio State University, 2009. http://rave.ohiolink.edu/etdc/view?acc_num=osu1245431229.
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Hussain, Amjad. "Workforce challenges : 'inclusive design' for organizational sustainability." Thesis, Loughborough University, 2013. https://dspace.lboro.ac.uk/2134/12578.
Full textAbstract:
Today's challenge for workforce management lies in providing a healthy, safe and productive working culture where people are valued, empowered and respected. Workforce diversity is becoming an essential aspect of the global workforce, and ageing is the most prominent and significant factor in this regard. Diversity brings many opportunities and challenges, as workers with different backgrounds, cultures, working attitudes, behaviours and age work together, and in future, the key to organizational effectiveness and sustainability will heavily depend on developing and sustaining inclusive work environments where people with their differences can co-exist safely and productively. Manufacturing organizations expect the highest levels of productivity and quality, but unfortunately the manufacturing system design process does not take into account human variability issues caused by age, skill, experience, attitude towards work etc. This thesis focuses on proposing an inclusive design methodology to address the design needs of a broader range of the population. However, the promotion and implementation of an inclusive design method is challenging due to the lack of relevant data and lack of relevant tools and methods to help designers. This research aims to support the inclusive design process by providing relevant data and developing new design methodologies. The inclusive design methodology suggested in this thesis is a three step approach for achieving a safe and sustainable work environment for workers, with special concern for older workers. The methodology is based on the provision of relevant human capabilities data, the capture and analysis of difference in human behaviour and the use of this knowledge in a digital human modelling tool. The research is focused on manual assembly through a case study in the furniture manufacturing industry and joint mobility data from a wide-ranging population has been analysed and the task performing strategies and behaviours of workers with different levels of skills have been recorded and analysed. It has been shown that joint mobility significantly decreases with age and disability and that skilful workers are likely to adopt safer and more productive working strategies. A digital human modelling based inclusive design strategy was found to be useful in addressing the design needs of older workers performing manufacturing assembly activities. This strategy validates the concept of using human capabilities data for assessing the level of acceptability of any adopted strategy for older workers, and suggests that the strategies adopted by skilful workers are more likely to be equally acceptable for older and younger workers keeping in view differences in their joint mobility. The overall purpose of this thesis is to present a road map towards the promotion and implementation of the inclusive design method for addressing workforce challenges and in future the same strategies might be implemented within a variety of other industrial applications. The proposed three step inclusive design methodology and getting a reasonable understanding of human variability issues along with the use of human capabilities data (joint mobility in this case) in a human modelling system for design assessment at a pre-design stage can be considered as the major contributions of this research.
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Wu, Chia-Hsiang, and 吳佳祥. "A Study on the Relationships among Line Maintenance Staff's Human Errors,Job Satisfaction,and Organizational Commitment in the Airline Industry." Thesis, 2018. http://ndltd.ncl.edu.tw/handle/8a38pj.
Full textAbstract:
碩士元智大學
管理碩士在職專班
106
Aircraft maintenance is a process of ensuring that all systems on the aircraft continue to perform their intended functions at the level of safety design and reliability. Without the contribution of maintenance personnel, the aviation industry can not operate, however, due to job characteristics, line maintenance tend to have higher error rate than other maintenance departments, which in turn poses a threat to flight safety. Human error is the result of interactions between individuals, workplaces, and organizational factors. It often has a negative impact on the job performance of maintainer, and may even result in flight incidents. Therefore, this study intends to study the relationship between human error and the organizational behaviors from the aspects of job satisfaction and organizational commitment of the line maintenance staff. This study conducted a questionnaire survey to collect data from the line maintenance staff of a major airline in Taiwan. A total of 241 valid questionnaires were collected. The results of statistical analysis revealed that the main error factors influencing the line maintenance staff include “Fatigue”, “Pressure”, “Stress” and “Destructive-Workplace Norms”.Job satisfaction has a negative impact on “Lack of Communication” , ”Leak of Awareness” , “Pressure” , “Fatigue” , and “Destructive-Workplace Norms” among human errors.Organizational commitment have a negative impact on “Lack of Communication” , “Leak of Awareness” , “Fatigue” , “Pressure” among human errors.
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Armitage, Gerry R. "Human error theory: relevance to nurse management." 2008. http://hdl.handle.net/10454/6786.
Full textAbstract:
NoAIM: Describe, discuss and critically appraise human error theory and consider its relevance for nurse managers. BACKGROUND: Healthcare errors are a persistent threat to patient safety. Effective risk management and clinical governance depends on understanding the nature of error. EVALUATION: This paper draws upon a wide literature from published works, largely from the field of cognitive psychology and human factors. Although the content of this paper is pertinent to any healthcare professional; it is written primarily for nurse managers. KEY ISSUES: Error is inevitable. Causation is often attributed to individuals, yet causation in complex environments such as healthcare is predominantly multi-factorial. Individual performance is affected by the tendency to develop prepacked solutions and attention deficits, which can in turn be related to local conditions and systems or latent failures. Blame is often inappropriate. Defences should be constructed in the light of these considerations and to promote error wisdom and organizational resilience. CONCLUSION AND IMPLICATIONS: Managing and learning from error is seen as a priority in the British National Health Service (NHS), this can be better achieved with an understanding of the roots, nature and consequences of error. Such an understanding can provide a helpful framework for a range of risk management activities.
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Tan, Samson. "A Dynamic, Probabilistic Fire Risk Model incorporating Technical, Human and Organizational Risks for High-rise Residential Buildings." Thesis, 2021. https://vuir.vu.edu.au/42814/.
Full textAbstract:
Fire events in high-rise residential buildings pose threats to both property and human life and upon investigation it is frequently revealed that the cause of a fire event is not simply due to technical errors. Often these investigations uncover human and organizational errors (HOEs) that contribute to fire risk and fire events. Many human factors identified in fire risk environments can be minimized through employee training and development while organizational factors, such as safety culture, can be changed over time through transformational interventions that shift existing mindsets. Probabilistic risk analysis (PRA) methods are modeling tools that allow fire risk professionals to estimate risk by computing several scenarios of what can go wrong, the likelihood of events occurring, and the consequences of the events. PRA often takes a fixed value of events occurring likelihood over the building design period, whereas it may change due to aging of a fire safety measure. PRA is an explicit methodology for complying with performance requirements of building codes, but existing PRA methods may underestimate safety risk levels by ignoring HOEs while focusing solely on technical risks and errors as well as not taking into account reliability changes over the time.
In this work, a systematic review identifies HOEs that can potentially affect risk estimates in fire safety modelling of high-rise buildings. The importance and uniqueness of high-rise buildings is mainly due to the special nature of buildings where fire-fighting techniques require different safety measures than in other industries. In addition, the height of high-rise buildings and the increased number of occupants result in longer evacuation times than other types of buildings or industrial plants. Evacuation times are increased further when the number of stairways in these buildings is limited. A wide range of HOEs have been identified as impacting risk in various industries such as offshore oil production and nuclear plants, but not all these identified HOEs will be appropriate for high-rise buildings. Important factors are those that emerge consistently from different published sources supported by quantitative case studies of events such as the Grenfell Tower fire in London and the fire in the Lacrosse building fire in Melbourne. The linking of published HOEs with errors identified from high-rise building fire case studies uncover HOEs likely to influence risk estimates. Quantifications of the impact of HOEs on risk estimates in other industries indeed justify additional research and inclusion of HOEs for risk estimates in high-rise buildings. This work uniquely connects HOEs from various industries to likely HOEs associated with risks in high-rise buildings to address an important gap in the literature. The research provides empirical quantitative studies, theoretical framework, and guidelines demonstrating how HOEs risks can be distilled to improve PRAs of fires in high-rise buildings.
To further address the gap, this work proposes a comprehensive Technical- Human-Organizational Risk (T-H-O-Risk) methodology to enhance existing PRA approaches by quantifying human and organizational risks. The methodology incorporates Bayesian Network (BN) analysis of HOEs and System Dynamics (SD) modeling for dynamic characterization of risk variations over time in high- rise residential buildings. Most current approaches assume that the relationships among HOEs are independent and current methods do not explain the interactions among these variables. An integrated T-H-O-Risk model overcomes this limitation by measuring causal relationships among variables and quantifying HOEs such as staff training, fire drill practices, safety culture and building maintenance. The model addresses the underestimation of risk resulting from not following the proper practices and regulations. Issues of selecting fire safety measures needed to reduce risk to an acceptable level are examined while evaluating the efficacy of active systems that are sensitive to HOEs. The methodology utilizes the “as low as reasonably practicable” (ALARP) principle in comparing risk acceptance for different case studies demonstrating the model’s value related to risk reduction with respect to initial designs of high-rise residential buildings.
By incorporating both BN and SD techniques, the T-H-O-Risk model developed in this research evaluates HOEs dynamically in an innovative and integrated quantitative risk framework. This is possible by incorporating factors that vary with time since event tree/fault tree (ET/FT) and BN alone cannot deal with dynamic characteristics of the process variables and HOEs. The model includes risk variation over time which is significantly better than contemporary methods that only provide static values of risks. Initially three case studies are conducted with limited number of scenarios for the purpose of validation to demonstrate the application of this comprehensive approach to the designs of various high-rise residential buildings ranging from 18 to 24 stories. Societal risks are represented in F-N curves. Results show that in general, fire safety designs that do not consider HOEs underestimate the overall risks significantly which can reach 40% in some extreme cases. Furthermore, risks over time due to HOEs vary by as much as 30% over 10 years. A sensitivity analysis indicates that deficient training, poor safety culture and ineffective emergency plans have significant impact on overall risk.
Subsequently, the application of the T-H-O-Risk methodology was expanded to seven designs of high-rise residential buildings (including earlier three) with 16 different technical solutions to quantify the impact of HOEs on different fire safety systems. The active systems considered are sprinklers, building occupant warning systems, smoke detectors, and smoke control systems. The results indicate that HOEs impact risks in active systems by approximately 20%, however, HOEs have a limited impact on passive fire protection systems. Large variations are observed in the reliability of active systems due to HOEs over time.
Finally, sensitivity and uncertainty analyses of HOEs were carried out on three selected buildings from the above seven. The sensitivity analysis again indicates that deficient training, poor safety culture and ineffective emergency plans have significant impact on overall risk. The model also identifies multiple cases where tenable conditions are breached. A detailed uncertainty analysis is carried out using a Monte Carlo approach to isolate critical parameters affecting the risk levels.
This research has developed a novel approach to enhance fire risk assessment methods using a holistic quantification of technical, human, and organizational risks for high-rise residential buildings which ultimately benefits future risk assessments providing more precise estimates. A significant contribution of this research involves the systematic identification of HOEs and their associated risks for consideration in future PRAs. By studying various trial designs, the impact of HOEs on fire safety systems is analyzed while demonstrating the robustness of the T-H-O-Risk methodology for high-rise buildings. The research lays foundations for next-generation building codes and risk assessment methods.
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Lopes, Celina Maria Nascimento Lizardo Torres. "Erros humanos : um estudo sobre erros pessoais e organizacionais na Direção Geral de Contribuições e Impostos de Cabo Verde." Master's thesis, 2018. http://hdl.handle.net/10400.14/27724.
Full textAbstract:
Tudo o que está sujeito a normas, regras e números é suscetível de erro.
Este estudo visa investigar os erros pessoais e organizacionais envolvidos na
reanálise da restituição do Imposto Único sobre o Rendimento das Pessoas Singulares do ano
2008, ocorridos na Direção Geral das Contribuições e Impostos em Cabo Verde e examinar os
erros mais predominantes. O método utilizado foi o estudo de caso, com recurso a recolha
documental e entrevista, baseado nos casos de Saurin et al. (2012) e Almeida e Vilela (2010).
Os tipos de erros apurados num total de 191 ocorrências foram agrupados em 55 categorias,
com maior incidência nos erros intitulados “Encargos familiares – filhos”, com 87 ocorrências
(46%). Em relação ao nível de gravidade, 185 destas ocorrências (96,9%) foram consideradas
“Muito Grave” e 6 (3,1%) “Grave”. Os resultados indicam que os erros pessoais predominam
sobre os erros organizacionais, na ordem de 54,5 % contra 45,5% e os erros resultam: de
interpretação errada de normas, informações imprecisas e insuficientes, deficiência de regras
de validação de dados, ausência de rotinas de manutenção do sistema, défices de gestão e de
planeamento, falta de estabelecimento de metas e falha nos procedimentos administrativos. A
dita reanálise traduziu-se em receitas brutas para o Estado no valor de 11.216.978$00 (0,36%
de receitas do IUR-PS), conquanto não foram apurados os gastos imprescindíveis à realização
destas receitas.
Esperamos que o resultado deste estudo forneça subsídios, para que a instituição
possa aprender com os erros, e crie condições para evitar que erros deste género aconteçam no
futuro e que o mesmo constitua um incentivo de pesquisa sobre a temática dos impostos e
afins.Everything that is subject to rules, rules and numbers is susceptible to error. This study aims to investigate the personal and organizational errors involved in the reanalysis of the restitution of the Individual Income Tax for the year 2008, occurred in the General-Directorate of Income Taxation in Cape Verde and to examine the most prevalent errors. The method used was the case study, using documentary collection and interview, based on the cases of Saurin et al. (2012) e Almeida e Vilela (2010). The types of errors found in a total of 191 occurrences were grouped into 55 categories, with the highest incidence in the errors titled "Family expenses - children", with 87 occurrences (46%). In relation to the severity level, 185 of these occurrences (96.9%) were considered "Very Severe" and 6 (3.1%) "Severe". The results indicate that personal errors predominate over organizational errors, in the order of 54.5% against 45.5% and errors result from: wrong interpretation of standards, inaccurate and insufficient information, deficiency of data validation rules, absence of system maintenance routines, management and planning deficits, lack of goal setting and failure of administrative procedures. The said reanalysis resulted in gross revenue for the State amounting to 11.216.978$00 (0, 36% of IUR-PS revenues), although the necessary expenses for the realization of these revenues were not determined. We hope that the result of this study will provide subsidies, so that the institution can learn from the mistakes, and create the conditions to avoid that errors of this sort happen in the future and that this study becomes a research incentive on the subject of taxes and related.
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(10711044), Benjamin R. Pratt. "Designing Work to Cultivate Mindfulness: An Attention-Based Approach to Work Design." Thesis, 2021.
Find full textAbstract:
In contemporary organizations, managing workers’
attention is more critical to success than managing workers’ temporal location.
Mindfulness, which represents an essential dimension of attention, has been
associated with many important individual and work outcomes. However, we know
relatively little about how mindfulness is cultivated at the individual level,
and the little we know places the individual in full control of cultivating
mindfulness; implicitly conceptualizing managers as relatively passive
characters in the cultivation of worker mindfulness. Integrating the
mindfulness literature with work design, I propose an attention-based model of
work design, through which key work characteristics are linked to worker
mindfulness through the mediating effects of psychological demands and
job-based psychological ownership. I test portions of this model with two samples. In
sample 1, I use survey data from 555 employees from a regional healthcare
system to examine the relationships between key work characteristics and
job-based psychological ownership. In sample 2, I use survey data from 211
individuals to test both the proposed job-based psychological ownership path to
mindfulness, as well as the proposed psychological demands path to mindfulness.
I end with a discussion of the findings, limitations, and opportunities for
future research.
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Jean, Dar-Fu, and 簡達夫. "THE IMPLICATION OF ORGANIZATIONAL LEARNING IN THE PREVENTION STRATEGY OF HUMAN ERROR--TAKE THE OPERATION/MAINTENANCE DEPARTMENT OF NUCLEAR POWER PLANT OF TAIWAN POWER COMPANY AS EXAMPLE." Thesis, 1999. http://ndltd.ncl.edu.tw/handle/23981746156439331642.
Full textAbstract:
碩士國立交通大學
經營管理研究所
87
ABSTRACTS The abnormal incident happened in last few years in the nuclear power plant of Taiwan power company had been major report subject of the press, accumulated incident happened in previous years, there was phenomena of reoccurrence in several cases. We discuss the cause subject to these phenomena are main defect of the existing human prevention strategy. The cause of these defect was due to the deficiency or incorrect of technical recognition of the personnel work under uncertain situation. This study subject to the limited learning resulting from deficiency of existing prevention strategy and try to seek a reasonable resolution based on the view of organization learning. First we discuss according to the characteristic of existing prevention strategy and its defect, understand and categorize respectively to the assumption of the key factors of each existing prevention strategy, and analyze the effective characteristic of each model of the resolution of reoccurrence provided by organization learning one by one, finally raise the feasible increment effect subject to all human error prevention strategy respectively according to the characteristic of these model, these are the implication of the organizational learning in prevention strategy of human error. Proving by the case example, this consequent is feasible in practice application, and found that a effective prevention strategy in addition to characteristic of synthesis, it possess mechanism of unfreezing, change, freezing as well. The purpose of the existence of these mechanism in the organization learning which serve as human error prevention strategy are no more than maintaining the weltanschauung (World View) of the mental model of the action client and the organization, response to the environment effectively and correctly, and prevent the reoccurrence of the human error.
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Lin, Chung-Ching, and 林中群. "Designing Safe Product Against Human Errors." Thesis, 1996. http://ndltd.ncl.edu.tw/handle/62932096990729487464.
Full textAbstract:
碩士國立成功大學
工業設計學系
84
Product deisgn is a process of encoding by means of form to communicationinformation about the structure, funtion, operation, and value of identityof a product. It is inevitably necessary for a user to do decoding task in order to understand how to use and operate a product apporiately. However,many human errors do occur due to the lack of effective design of a product form to communicateadequate safety messages. This study focuses on the recognition of a productform which may express itself better. With thorough investigation of accidents in operating a product, some human errors are identified andcategorized for developing appropriate forms to effectively communicate safetyinformation. An empirical study of product forms was conducted to test someideas of safety-related message encoding in product design. As a result, some guidelines are proposed for designers to design safer products to avoid human errors in operating a product.
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De, Reuck Samantha. "Factors underlying human errors in air traffic control." Thesis, 2015. http://hdl.handle.net/10539/16984.
Full textAbstract:
A research project submitted in partial fulfilment of the requirements for the degree of MA by coursework and research report in the field of Industrial/Organisational Psychology in the Faculty of Humanities, University of the Witwatersrand, Johannesburg, 14th February 2014The main objective of Air Traffic Control is to ensure the safe and orderly movement of aircraft through airspace. The primary aim of this study was to explore and identify the factors underlying human error in Air Traffic Control, based on safety event reports from the years 2010 to 2012. A total of 84 incident reports were analysed from airports spanning South Africa. Core factors that were explored included human factors, demographic factors, external factors, shift variables, risk factors and stated causal factors. This was done through the use of content analysis, cluster analyses and logistic regressions. The main results showed that errors in information processing factors, physical workplace designs, poor co-ordination standards and lack of memory cues are predictors of safety events. It was also established that lapses are predictors of poor information processing in controllers whilst poor workplace designs are a predictor of lapses. Finally, a lapse in itself is a predictor of safety events. These finding may direct future research into the possibility of lapses as a mediating variable between poor workplace designs and information processing errors.
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Wang, Jia-Wei, and 王嘉偉. "Feasibility Study on Quantitative Analysis of Human Errors." Thesis, 2008. http://ndltd.ncl.edu.tw/handle/22616204569248313196.
Full textAbstract:
碩士國立成功大學
航空太空工程學系碩博士班
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The goal of this research is the feasibility of quantitating human errors from engineering angles. According Human Factor Analysis and Classification System human errors classification, this research using flight safety margin of safety theory and flight simulator platform for human factors research in flight safety. The unsafe acts of operator in HFACS, we selected Skill-based Errors、Decision Errors and Perceptual Errors to discuss human errors during the flight with pilots. Base on the flight simulator platform for human factors research in flight safety, we simulated the 3rd, the 4th and the 5 landing section of 5 landing procedure. Quantitated the result of the simulation by using the flight safety margin of safety theory, we can figure out the Average Disparity Safety Margin（ADSM）between normal value and unusually value. According to the ADSM in all kinds of human errors, we can tell the quantification of the seriousness of the human errors.
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Garcia, Vasquez Javier. "System dynamics modeling of human errors at mining operations." Thesis, 2006. http://hdl.handle.net/2429/17952.
Full textAbstract:
There have been many studies about the causes of incidents in different industries, and the mining industry is no exception. From all of these studies, companies and researchers have concluded that the principal reason for incidents in a mining operation is due to human errors. The aim of this research is to use system dynamics to devise a model of human errors leading to incidents. The model includes the modification of the rate of worker errors through feedback (experience and training) and the modification of the learning or experience curve when training programs are implemented. The combination of latent and worker errors leading to incidents is also modeled. Since the errors, combinations of errors and changes due to training each occur at different frequencies, the model predicts some interesting interactions.Applied Science, Faculty of
Mining Engineering, Keevil Institute of
Graduate