957 resultados para Human Error


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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

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In 2008, academic researchers and public service officials created a university extension studies platform based on online and on-site meetings denominated "Work-Related Accidents Forum: Analysis, Prevention, and Other Relevant Aspects. Its aim was to help public agents and social partners to propagate a systemic approach that would be helpful in the surveillance and prevention of work-related accidents. This article describes and analyses such a platform. Online access is free and structured to: support dissemination of updated concepts; support on-site meetings and capacity to build educational activities; and keep a permanent space for debate among the registered participants. The desired result is the propagation of a social-technical-systemic view of work-related accidents that replaces the current traditional view that emphasizes human error and results in blaming the victims. The Forum uses an educational approach known as permanent health education, which is based on the experience and needs of workers and encourages debate among participants. The forum adopts a problematizing pedagogy that starts from the requirements and experiences of the social actors and stimulates support and discussions among them in line with an ongoing health educational approach. The current challenge is to turn the platform into a social networking website in order to broaden its links with society.

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In the last 20-30 years, the implementation of new technologies from the research centres to the food industry process was very fast. The infrared thermography is a tool used in many fields, including agriculture and food science technology, because of it's important qualities like non-destructive method, it is fast, it is accurate, it is repeatable and economical. Almost all the industrial food processors have to use the thermal process to obtain an optimal product respecting the quality and safety standards. The control of temperature of food products during the production, transportation, storage and sales is an essential process in the food industry network. This tool can minimize the human error during the control of heat operation, and reduce the costs with personal. In this thesis the application of infrared thermography (IRT) was studies for different products that need a thermal process during the food processing. The background of thermography was presented, and also some of its applications in food industry, with the benefits and limits of applicability. The measurement of the temperature of the egg shell during the heat treatment in natural convection and with hot-air treatment was compared with the calculated temperatures obtained by a simplified finite element model made in the past. The complete process shown a good results between calculated and observed temperatures and we can say that this technique can be useful to control the heat treatments for decontamination of egg using the infrared thermography. Other important application of IRT was to determine the evolution of emissivity of potato raw during the freezing process and the control non-destructive control of this process. We can conclude that the IRT can represent a real option for the control of thermal process from the food industry, but more researches on various products are necessary.

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Objective Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular and for improving healthcare quality and patient safety in general. Method The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. Results The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. Conclusions Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

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OBJECTIVE: Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general. METHOD: The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. RESULTS: The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. CONCLUSIONS: Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

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Software Product Line Engineering has significant advantages in family-based software development. The common and variable structure for all products of a family is defined through a Product-Line Architecture (PLA) that consists of a common set of reusable components and connectors which can be configured to build the different products. The design of PLA requires solutions for capturing such configuration (variability). The Flexible-PLA Model is a solution that supports the specification of external variability of the PLA configuration, as well as internal variability of components. However, a complete support for product-line development requires translating architecture specifications into code. This complex task needs automation to avoid human error. Since Model-Driven Development allows automatic code generation from models, this paper presents a solution to automatically generate AspectJ code from Flexible-PLA models previously configured to derive specific products. This solution is supported by a modeling framework and validated in a software factory.

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Bridge building is a highly uncertain endeavour that entails considerable risk, as attested to by the succession of construction-related incidents and accidents recently reported in Spain and elsewhere. While efforts are being made to improve on-site safety, many issues are still outstanding, such as the establishment of reliability requirements for the ancillary systems used. The problems that must be dealt with in everyday practice, however, are more elementary and often attributable to human error. The overall organisation of the use of bridge construction equipment is in need of improvement. Close cooperation between the bridge engineers responsible for construction planning and ancillary element suppliers is imperative, for flawed interaction between building equipment and the bridge under construction may generate structural vulnerability. External quality assurance should likewise be mandatory

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Summary. On 11 March 2011, a devastating earthquake struck Japan and caused a major nuclear accident at the Fukushima Daiichi nuclear plant. The disaster confirmed that nuclear reactors must be protected even against accidents that have been assessed as highly unlikely. It also revealed a well-known catalogue of problems: faulty design, insufficient back-up systems, human error, inadequate contingency plans, and poor communications. The catastrophe triggered the rapid launch of a major re-examination of nuclear reactor security in Europe. It also stopped in its tracks what had appeared to be a ‘nuclear renaissance’, both in Europe and globally, especially in the emerging countries. Under the accumulated pressure of rising demand and climate warming, many new nuclear projects had been proposed. Since 2011 there has been more ambivalence, especially in Europe. Some Member States have even decided to abandon the nuclear sector altogether. This Egmont Paper aims to examine the reactions of the EU regarding nuclear safety since 2011. Firstly, a general description of the nuclear sector in Europe is provided. The nuclear production of electricity currently employs around 500,000 people, including those working in the supply chain. It generates approximately €70 billion per year. It provides roughly 30% of the electricity consumed in the EU. At the end of 2013, there were 131 nuclear power reactors active in the EU, located in 14 countries. Four new reactors are under construction in France, Slovakia and Finland. Secondly, this paper will present the Euratom legal framework regarding nuclear safety. The European Atomic Energy Community (EAEC or Euratom) Treaty was signed in 1957, and somewhat obscured by the European Economic Community (EEC) Treaty. It was a more classical treaty, establishing institutions with limited powers. Its development remained relatively modest until the Chernobyl catastrophe, which provoked many initiatives. The most important was the final adoption of the Nuclear Safety Directive 2009/71. Thirdly, the general symbiosis between Euratom and the International Atomic Energy Agency (IAEA) will be explained. Fourthly, the paper analyses the initiatives taken by the EU in the wake of the Fukushima catastrophe. These initiatives are centred around the famous ‘stress tests’. Fifthly, the most important legal change brought about by this event was the revision of Directive 2009/71. Directive 2014/87 has been adopted quite rapidly, and has deepened in various ways the role of the EU in nuclear safety. It has reinforced the role and effective independence of the national regulatory authorities. It has enhanced transparency on nuclear safety matters. It has strengthened principles, and introduced new general nuclear safety objectives and requirements, addressing specific technical issues across the entire life cycle of nuclear installations, and in particular, nuclear power plants. It has extended monitoring and the exchange of experiences by establishing a European system of peer reviews. Finally, it has established a mechanism for developing EU-wide harmonized nuclear safety guidelines. In spite of these various improvements, Directive 2014/87 Euratom still reflects the ambiguity of the Euratom system in general, and especially in the field of nuclear safety. The use of nuclear energy remains controversial among Member States. Some of them remain adamantly in favour, others against or ambivalent. The intervention of the EAEC institutions remains sensitive. The use of the traditional Community method remains limited. The peer review method remains a very peculiar mechanism that deserves more attention.

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Mode of access: Internet.

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Mode of access: Internet.

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National Highway Traffic Safety Administration, Washington, D.C.

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National Highway Traffic Safety Administration, Washington, D.C.

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National Highway Traffic Safety Administration, Washington, D.C.

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National Highway Traffic Safety Administration, Washington, D.C.