A Behavioral Intervention for Reducing Postcompletion Errors in a Safety-Critical System

نویسندگان

  • Joseph D. McDonald
  • Francis T. Durso
چکیده

OBJECTIVE We investigated the effectiveness of a theoretically motivated intervention at reducing procedural errors in train yard operations, where making these errors could be costly or life-threatening. BACKGROUND A widespread and persistent memory error that people commit on a daily basis is the postcompletion error (PCE), that is, forgetting to complete the final step of a procedural task in which the final step occurs after completion of the task goal. PCEs occur in the railroad industry when a locomotive conductor changes the direction of a rail switch but fails to report this change. This particular error could contribute to unsafe conditions as another train traveling on the same track could derail. Although training can help reduce some of the factors leading to unsafe conditions on the rail, research has demonstrated that PCEs are different from other errors of omission in that they cannot be eliminated through training, which makes them a difficult problem to address. METHOD Twenty-eight undergraduates completed train yard tasks within a mid-fidelity simulator used in commercial rail operations for training. Each participant received the behavioral intervention in one block and no intervention in another. Specifically, participants were required to perform an additional task designed to remind participants of the postcompletion step. RESULTS Our intervention significantly reduced PCE rates in the context of train yard operations, on average by 65%. CONCLUSION We discuss implications of the effectiveness of our intervention at reducing train yard accidents and how this outcome can contribute to the literature on the cause of PCEs. APPLICATION In cases such as the railroad industry, where redesigning technology is prohibitive, our behavioral intervention is an effective alternative for significantly reducing PCEs.

برای دانلود متن کامل این مقاله و بیش از 32 میلیون مقاله دیگر ابتدا ثبت نام کنید

ثبت نام

اگر عضو سایت هستید لطفا وارد حساب کاربری خود شوید

منابع مشابه

Investigating the Effect of Senior Managers' Compliance in Reporting Nurses' Treatment Errors in Pediatric Wards

Background: The occurrence of medical errors in therapeutic centers is important due to its critical nature in terms of health, patient safety, and notable clinical and economic outcomes. One of the solutions to manage this problem in the field of nursing is error reporting and recording. Error reporting, on one hand, improves patient care quality and safety and; on the other hand, provides val...

متن کامل

Professional errors and patient safety in intensive cardiac care unit:

Abstract Introduction: Use of progressive technology, clinical skills and caring methods appropriate to critical situations of patient in intensive Cardiac Care Unit is probably related to professional errors and disorder in patient safety. There is a little data about this subject. Objective: The aim of this study was to explore professional errors and patient safety in Cardiac Care Unit. Meth...

متن کامل

A Real-Time Eye Tracking System for Predicting and Preventing Postcompletion Errors

Procedural errors occur despite the user having the correct knowledge of how to perform a particular task. Previous research has mostly focused on preventing these errors by redesigning tasks to eliminate error prone steps. A differentmethod of preventing errors, specifically postcompletion errors (e.g., forgetting to retrieve the original document from a photocopier), has been proposed by Ratw...

متن کامل

Effect of risk management program on the rate of medication errors among intensive care unit nurses

Background & Aim: Patient safety in general and medication errors in particular are the important indicators of hospital care quality. Risk management is an important and fundamental approach to preventing events caused by medication errors. The aim of this study was to determine the effect of risk management program on the rate of medication errors among intensive care unit nurses. Methods & ...

متن کامل

Electronically Prescribing: A new Policy in Iranian Hospitals

Medication Errors (MEs) as one of the most important medical errors in hospitals are common, expensive, and sometimes harmful to patients. Several strategies such as Computerized Provider Order Entry (CPOE) and wristband barcoding are used for decreasing MEs. The role of new technologies is emphasized in the policies and planning in the health system in Iran. Worldwide, CPOE is a new technology...

متن کامل

ذخیره در منابع من


  با ذخیره ی این منبع در منابع من، دسترسی به آن را برای استفاده های بعدی آسان تر کنید

برای دانلود متن کامل این مقاله و بیش از 32 میلیون مقاله دیگر ابتدا ثبت نام کنید

ثبت نام

اگر عضو سایت هستید لطفا وارد حساب کاربری خود شوید

عنوان ژورنال:
  • Human factors

دوره 57 6  شماره 

صفحات  -

تاریخ انتشار 2015