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Book ChapterDOI

Socio-Technical Probabilistic Risk Assessment: Its Capabilities and Limitations

01 Jan 2004-pp 1270-1275
TL;DR: This paper explores the emerging process of socio- technical probabilistic risk assessment (ST-PRA) that is being used by operational managers to identify and mitigate operational risks within complex socio-technical systems such as aerospace and healthcare.
Abstract: Probabilistic risk assessment (PRA) is not new to the system designer. To the operational manager, however, PRA is virtually unknown. This paper explores the emerging process of socio-technical probabilistic risk assessment (ST-PRA) that is being used by operational managers to identify and mitigate operational risks within complex socio-technical systems such as aerospace and healthcare. What are the strengths of modeling socio-technical risks using fault trees, and what are the limitations of fault trees and the probability estimates inherent in probabilistic risk assessment?
Citations
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Journal ArticleDOI
TL;DR: A theoretical model for reducing medication delivery errors and a set of workflow design rules for healthcare professionals to continuously reduce medication Delivery errors are presented.
Abstract: Medication errors are major safety concerns in all hospital settings. The insufficient knowledge about managerial and process improvement strategies required to reduce medication errors can be considered as one of the most important factors holding back hospitals from achieving the desired goals for patient safety. However, strategies for medication error reduction cannot be successfully implemented without a clear understanding of factors affecting medication delivery errors. This paper presents a study in which healthcare professionals’ perceptions on three factors, namely (1) technical complexity of tasks/connections; (2) resources problems; and (3) qualification of human resources, are analyzed within the medication delivery system at one community hospital. The outcomes of this research are a theoretical model for reducing medication delivery errors and a set of workflow design rules for healthcare professionals to continuously reduce medication delivery errors.

22 citations


Cites background from "Socio-Technical Probabilistic Risk ..."

  • ...Although PRA is not a new concept in aerospace industry [42–43], it is a fairly new concept in healthcare [44–45]....

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Book ChapterDOI
01 Jan 2004
TL;DR: The use of Probabilistic Risk Assessment (PRA) has often been an accepted safety research tool in studying risk in technical systems, it has had limited use in predominately human systems in which human limitations and failure represent substantial risks as mentioned in this paper.
Abstract: Government research agencies can play an important role in helping to shape a research agenda through the research methods and techniques that they fund through grants and contracts. While the use of Probabilistic Risk Assessment (PRA) has often been an accepted safety research tool in studying risk in technical systems, it has had limited use in predominately human systems in which human limitations and failure represent substantial risks. There is a need to apply PRA to more human based systems where the role of human behavior can represent a substantial portion of probable risk Two U.S. federal governmental research agencies are now using socio-technical probabilistic risk assessment as an important research tool to meet program objectives as part of their overall safety research efforts. The Agency for Healthcare Research and Quality (AHRQ) is the federal agency designated to lead the research effort in the area of medical error and patient safety while the National Aeronautics and Space Administration has responsibility in research in aviation and space safety management. Both AHRQ and NASA are advancing the use of probabilistic safety assessment through active research programs which are described.

14 citations


Cites background from "Socio-Technical Probabilistic Risk ..."

  • ...For example, in the shuttle processing work environment, a partial risk model of ground-processing-induced inflight anomaly (GPI-IFA) risk has been built [10]....

    [...]

Journal ArticleDOI
TL;DR: ST-PRA is an attempt to model complex human variation in the way the authors perform their work, where, given behavioral norms, 1 task can be performed many different ways within 1 risk model.
Abstract: This article describes the process of socio-technical probabilistic risk assessment (ST-PRA). What makes ST-PRA an evolutionary step is that the entire risk model is made up of human errors and at-risk behaviors, attempting to model the as-is state of a predominantly human process. Where traditional PRA will generally model a technical system with some input of human errors (e.g., THERP or WASH 1400; Kanki & Marx, 2004), the ST-PRA attempts to model human errors and human variations, where, given behavioral norms, 1 task can be performed many different ways within 1 risk model. ST-PRA is an attempt to model complex human variation in the way we perform our work.

6 citations


Cites background from "Socio-Technical Probabilistic Risk ..."

  • ...In other environments, such as aircraft ground damage, where the undesirable outcome is visible, the focus group model can be directly compared to a datadeveloped model.(2)...

    [...]

  • ...Additionally, because operator environments and operator use of equipment will vary between operators it is also difficult for the design engineer to model operational risk.(2) In contrast to PRA of mechanical systems with some limited modeling of human errors; socio-technical probabilistic risk assessment (ST-PRA) is the PRA of socio-technical systems with limited modeling of equipment failure....

    [...]

References
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Book ChapterDOI
01 Jan 2004
TL;DR: The use of Probabilistic Risk Assessment (PRA) has often been an accepted safety research tool in studying risk in technical systems, it has had limited use in predominately human systems in which human limitations and failure represent substantial risks as mentioned in this paper.
Abstract: Government research agencies can play an important role in helping to shape a research agenda through the research methods and techniques that they fund through grants and contracts. While the use of Probabilistic Risk Assessment (PRA) has often been an accepted safety research tool in studying risk in technical systems, it has had limited use in predominately human systems in which human limitations and failure represent substantial risks. There is a need to apply PRA to more human based systems where the role of human behavior can represent a substantial portion of probable risk Two U.S. federal governmental research agencies are now using socio-technical probabilistic risk assessment as an important research tool to meet program objectives as part of their overall safety research efforts. The Agency for Healthcare Research and Quality (AHRQ) is the federal agency designated to lead the research effort in the area of medical error and patient safety while the National Aeronautics and Space Administration has responsibility in research in aviation and space safety management. Both AHRQ and NASA are advancing the use of probabilistic safety assessment through active research programs which are described.

14 citations

Proceedings ArticleDOI
22 Jan 1996
TL;DR: In this article, the authors describe how NASA appears to be undergoing a paradigm shift in its approach to Space Shuttle risk management and how advances in the state-of-the-art have now made quantitative risk assessments powerful risk management tools, especially for programs such as the Shuttle.
Abstract: The authors describe how NASA appears to be undergoing a paradigm shift in its approach to Space Shuttle risk management. At least in some quarters, there appears to be a recognition that advances in the state-of-the-art have now made quantitative risk assessments powerful risk management tools, especially for programs such as the Shuttle with its ever increasing flight and test history data sets and its ever shrinking operational budget.

7 citations

Proceedings ArticleDOI
12 May 2008
TL;DR: A Probabilistic Risk Assessment (PRA) of the Space Shuttle system has recently been completed as mentioned in this paper, which is the first integrated quantitative assessment of the risk of the loss of the shuttle vehicle from 3 seconds prior to liftoff to wheel stop at mission end.
Abstract: A Probabilistic Risk Assessment (PRA) of the Space Shuttle system has recently been completed. This year‐long effort represents a development resulting from seven years of application of risk technology to the Space Shuttle. These applications were initiated by NASA shortly after the Challenger accident as recommended by the Rogers and Slay Commission reports. The current effort is the first integrated quantitative assessment of the risk of the loss of the shuttle vehicle from 3 seconds prior to liftoff to wheel‐stop at mission end. The study which was conducted under the direction of NASA’s Shuttle Safety and Mission Assurance office at Johnson Spaceflight Center focused on shuttle operational risk but included consideration of all the shuttle flight and test history since the beginning of the program through Mission 67 in July of 1994.

5 citations

01 Jan 2002
TL;DR: I will be describing several innovative approaches to risk that have been developing over the last five or six years and introducing three types of risk in order to set up a context for describing these new approaches.
Abstract: As researchers, designers, operators, and managers of complex, high-risk operations, we share an interest in human performance tools that can help us assess and manage risk. Through effective risk management, we seek to achieve the highest levels of operational and personal safety as a top priority. At the same time, however, operations must prove themselves efficient and effective in a time of dwindling resources and an unpredictable economy. In light of these conditions, we, more than ever, need reliable and valid tools to assess risk so that resources can be managed effectively and the balance of safety and performance is optimized. I will be describing several innovative approaches to risk that have been developing over the last five or six years. But first, I would like to introduce three types of risk in order to set up a context for describing these new approaches. The three risk types are 1) design risk, 2) process risk, and 3) the risk of human error. As their names suggest, they refer to different targets and serve different purposes although I will argue that they have been mixed and merged in a variety of helpful and unhelpful ways. In spite of the fact that the different risk types often share analysis tools, their distinct objectives and limitations should provide guidance for their best use. The new initiatives I will describe cross the boundaries of these risk types as they combine to create a more robust and expanded risk description.

3 citations