Human error rates

INTENT Human error rate assessment for INTENTion-based errors I Gertman ct al., 1992... 

The LER-HEP method (NUREG/ CR-3519) is a means of analyzing field data to estimate HEPs. It considers available data on specific human errors in similar to those being considered in the risk as.sessment. The application of the method in NUREG/CR-3519 is to the Licensee Event Report (LER) file so it is called the LER-HEP method. For each error analyzed by this method, an error rate is derived by dividing the number of similar errors by the estimated number of... 

S.2.9 Technique for Human Error Rate Prediction (THERP)... 

List of the generic human error probabilities used to determine a base error rate for each human error considered, and... 

The uncertainties in human error rates may be within the stated uncertainty bounds, but such is not demonstrated from sparse experiments. Both the qualitative description of the human interaction logic and the quantitative assessment of those actions rely on the virtually untested judgment of experts. 

If the results of the qualitative analysis are to be used as a starting-point for quantification, they need to be represented in an appropriate form. The form of representation can be a fault tree, as shown in Figure 5.2, or an event tree (see Bellamy et al., 1986). The event tree has traditionally been used to model simple tasks at the level of individual task steps, for example in the THERP (Technique for Human Error Rate Prediction) method for human reliability... 

THERP Techniques for human error rate prediction... 

Evaluate the result in relation to quality aspects, including those not readily expressed as postconditions, such as error rate, cycle time, and costs. In the end, this technique can only suggest alternatives. Human, political, and many other constraints will influence the decision. 

In writing on human error, Senders and Moray (1991, p. 128) conclude Human error rates can be reduced to as low a level as desired, at some unknown cost. The occurrence of a particular error at a particular instant, however, cannot absolutely be prevented. Even if the patient suffers no permanent harm, a service failure or mistake in a pharmacy is a significant event. The consequences of a service failure or mistake in a pharmacy include a deterioration of trust in the pharmacist and the system, the spread of negative word-of-mouth advertising, the possibility of legal action, possible board of pharmacy involvement, the erosion of customer patronage, and a diminished level of profit (see Chapters 7, 28, and 30 on minimizing the occurrence of prescription errors). 

The third aspect is the high error rate and lack of efficient DNA repair systems, leading to a high mutation rate for mtDNA. It is estimated that mtDNA is 7-17 times more prone to mutation than somatic DNA. These aspects of mitochondrial biogenesis lead to the production of mutant mtDNA, contributing to the overall degree of heteroplasmy in human tissues. 

Practitioners and consumers often want to know the acceptable medication error rate. There is no benchmark. A zero error rate is desired, but unattainable because of human factors. If organizations can determine measuring points and consistently follow them, it might be possible to determine an internal benchmark to be used for quality improvement purposes. However, because the parameters of the measurement are unlikely to be duplicated elsewhere, use of the number for external comparisons is not valid. 

In contrast, the standard for the human genome project is an error rate of <0.01% (Collins et al., 1998). ESTs may contain substitutions, deletions, or insertions compared with the parent mRNA sequence. The region of an EST between positions 100 and 300 may be the most accmate part of the sequence (Hillier et al., 1996). 

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