safety

Fun with confusing medication names!

February 2, 2012
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Check out this post from The Consumerist about how unhappy the FDA is with Durezol and Durasal. A hint: It’s ok if you accidentally use Durezol when you wanted Durasal, but the penalty is high for using Durasal instead of Durezol!* This link contains an explanation of the names: When drugs are submitted to the FDA for approval, the Agency carefully screens [...]

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Excerpts from the NASA ASRS

January 28, 2012
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One of my students last semester (thanks, Ronney!) turned me on the “Callback” publication from the NASA Aviation Safety Reporting System. These are almost all first person stories written as case studies of errors and accidents or near accidents. There aren’t so many that it falls under my list of neat databases, but it certainly is interesting reading. I’ve collected [...]

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Paper isn’t so bad…

December 15, 2011

One thing that annoys me is the silly argument that paper is bad or paper kills. Such hollow arguments are used to encourage technology adoption in airplane cockpits, the class room, and hospitals. Usually they are associated with silly statistics about how much paper is saved or how much less weight is carried, or how much easier it will be [...]

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Rudder knob in cockpit mistaken for door latch

November 1, 2011
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Any aviation experts want to chime in about a knob turning a plane upside down? Also, please note this was characterized as “pilot error.” Pilot error causes airliner to flip, fly upside down From the article: According to the safety board, an analysis of the aircraft’s digital flight recorder indicated the co-pilot, alone in the cockpit while the captain used [...]

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Verdict Reached for Air France Rio Crash

July 29, 2011
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The BBC has reported the incident analysis of the Air France crash that killed 228 people was due to lack of pilot skill in dealing with a high altitude stall. Here is a link to the BEA Report from the Bureau d’Enquetes et d’Analyses. It’s a frightening read, as they give a moment by moment analysis of the last minutes in the cockpit. No emergency [...]

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Failure to Design Out, Guard, or even Warn Results in Worker Pulled Through 5-inch Opening

June 3, 2011

The story of a UK man who was pulled through a small opening meant for steel poles is in the news again as the companies involved pleaded guilty to not having safety measures in place. Read the article here (with a picture of the machine). I’ve excerpted the reported accident factors below: “His clothing snagged on the machine and he was [...]

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Radiation: The Difficulty of Monitoring the Invisible – Post 2 of 2

April 27, 2011
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This post continues the list of articles on HF-related errors in radiation delivering healthcare devices. As Technology Surges, Radiation Safeguards Lag But the technology introduces its own risks: it has created new avenues for error in software and operation, and those mistakes can be more difficult to detect. As a result, a single error that becomes embedded in a treatment plan can [...]

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Radiation: The Difficulty of Monitoring the Invisible – Post 1 of 2

April 22, 2011
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Lately, I have noticed a plethora of stories on human factors mistakes with medical equipment that delivers radiation. I have collected them here for those who are interested in this problem. At times a computer bug was at fault, but often radiation overdoses came from: inadequate training (and perhaps a poor display, but those are not available for me to examine) non-transferrable mental [...]

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Furniture-flavored Pancakes

October 20, 2010

Things are quiet because we’re both hammered by the Fall semester. But enjoy this humorous image of a lack of discriminability in product packaging (via Consumerist):

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HF Potpourri

September 20, 2010

Social networking for your car? As if we need another distraction while driving.  A new system (Bump.com) connects drivers by license plate so you can text message that person that cut you off (Thanks Paul!). Harry Brignull (of the 90percentiseverything blog) collects egregious examples of evil interfaces in his Dark Patterns website. Dark Patterns: User Interfaces Designed to Trick People [...]

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Blogging APA Division 21: The Cost of Automation Failure

August 27, 2010
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Arathi Sethumadhavan, currently of Medtronic and recently of Texas Tech, was this year’s winner of the George E. Briggs dissertation award, for the best dissertation this year in the field of applied experimental psychology. Her advisor was Frank Durso. Her work was inspired by our need to increase automation in aviation, due to increases in air traffic. However, automation does [...]

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Too standardized? – The problem of tube identification in hospitals

August 25, 2010
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When it comes to efficiency, creating standard sizes and connections saves money, production efforts, and makes for easy substitution when one runs out of an object. For example, I was delighted that lid for one brand of pot perfectly fit my new frying pan. Unfortunately, there are times when we do not want parts of one object to fit another [...]

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The Zero-Fatality Car

August 6, 2010
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I ran across this fascinating article from ComputerWorld on Volvo’s goal of creating a zero fatality car by 2020. As I read it, a number of human factors issues jumped out at me, but the focus is almost entirely on engineering issues. This does not mean Volvo will ignore the human factor. After all, I’ve previously posted on their well-done [...]

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The Human Factors of Weapons

July 16, 2010

James R. in California sends along a tragic story of police officer confusing his taser with his firearm.  The news story can be found here.  Here’s what James says: Here in CA there is a big to do over the shooting death of a young man (Oscar Grant) by a BART police officer Johannes Mehserle.  Apparently, Mr. Grant was being [...]

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Mining Tragedy Update

July 15, 2010
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There is new information on the West Virginia coal mine tragedy where the methane detectors were disabled to prevent automatic shut down of the machinery. This comes from NPR: Methane monitors are mounted on the massive, 30-foot-long continuous miners because explosive gas can collect in pockets near the roofs of mines. Methane can be released as the machine cuts into [...]

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Human Factors and Health care: Tackling Inefficiencies

July 12, 2010
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I came across two examples of human factors angles in health care. The first is from the NPR show Planet Money.  The show focuses on how much inefficiency and waste there is in medical billing. The whole podcast is worth listening to, but there is one bit that made me laugh out loud (fast-forward to 10:35). Codes (NDC number) are [...]

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