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THELACKOFHUMANRELIABILTYDATAISA
BARRIERTOTHEATTAINMENTOFNSABBS
RISKREDUCTIONOBJECTIVES
GavinHuntleyFenner,PhD
NASGainofFunctionSymposium
March1011,2016
TOPICS
Copyright2016
WhatisHumanFactors?
TheroleofHumanFactorsdata
inbiosafetyandbiosecurity
Theopportunity:Wehavethe
meanstoknow
Futureoptions
WHATISHUMANFACTORS?
Humanerrorisestimatedasfactorin:
>80%ofmotorvehicleaccidents
80%ofmedicalerrors
60%to80%ofaviationaccidents
Sources:Kohn,LindaT.,JanetM.Corrigan,andMollaS.Donaldson,eds.ToErrIsHuman::BuildingaSaferHealthSystem.Vol.627.NationalAcademiesPress,2000.
Foushee,H.Clayton."Dyadsandtriadsat35,000feet:Factorsaffectinggroupprocessandaircrewperformance."AmericanPsychologist 39.8(1984):885.Cooper,
JeffreyB.,etal."Preventableanesthesiamishaps:astudyofhumanfactors."Anesthesiology 49.6(1978):399406.AsreportedintheFHWAHighwaySafety
ImprovementProgramManual,EC/IRUStudy;
3
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Thestudyofhumanreliability,drawingonan
understandingofhumancapabilitiesand
limitationsinvariousenvironments.
Thelackofhuman
factorsresearchin
thelifesciencesis
somethingthatneeds
tobeaddressed.
Casagrande
TheU.S.governmentshould
continueeffortswhichwill
fosteracultureofresponsibility
thatwillsupportnotonlythesafe
conductofGOFstudiesofconcern
butofallresearchinvolving
pathogens
4
Sources:
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FOCUSONNSABBRECOMMENDATON4AND
TYPESOFDATATOACHIEVETHEOBJECTIVE
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HUMANERRORHASINCREASED
PROPORTIONALLYASACONTRIBUTORTO
ACCIDENTS
Sources:AsreportedintheFHWAHighwaySafetyImprovementProgramManual,EC/IRUStudy;Hollnagel,E.(1993).Thereliabilityofcognition:
Foundationsofhumanreliabilityanalysis,London,UK:AcademicPress
Increasedfatiguedue
tohoursworked
Cellphonesandother
distractions
PoorWorkingPosture
Load Workingwith
sharp,hot,coldor
toxic/hazardous
objects
Personnelprotective
equipmentmaymake
workmoretaxing.
Reduced
applicationofskill
Impairedcognitive
functioning
Sources:MaximizingUserSafetyThroughHumanFactorsDesign,LabconcowhitepaperbyBrianGarrett(2013)
Copyright2016
PHYSICALANDCOGNITIVESTRESSES
UNDERMINEHUMANRELIABILITY
Despiteadvancesintechnology,
instrumentsandPPE:
.humanerrorremainsoneofthe
mostimportantfactorsattheoriginof
accidents
7
Sources:
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THEWHOCALLSOUTHUMANERRORASA
PRIMARYLABBIOSECURITYCONCERN
Thestateofknowledgeofthe
ratesandconsequencesofhuman
errorsinlifesciencelaboratoriesis
toopoortodeveloprobust
predictionsoftheabsolute
frequencywithwhichlaboratory
accidentswillleadtolaboratory
acquiredinfections...
8
Sources:
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THEREISANIMPERATIVETOCOLLECTBETTER
DATA(Gryphon,2016)
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NOSOLACEFROMFEWADVERSEEVENTS,AS
FORENSICSSHOWSHIDDENORLATENTDATA
manyotherincidentsand
accidentshaveoccurred,
mainlyasaresultofhuman
errororequipmentfailure.
Fortunately,most
incidents/accidentsdonot
haveseriousconsequences
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2009GAOINVESTIGATIONHIGHLIGHTED
UNDERAPPRECIATEDHUMANERROR
No.
HumanFactorsprovidestools
fordesigning,implementing
andmaintainingsystemsin
whicherrorshavelimited
impactwhentheydooccur.
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DOESTHEINEVITABILITYOFHUMANERROR
ARGUEAGAINSTCONTINUINGGOFRC?
TrainingTarget
Risk Reduction
Seasonal
Influenza
7x
Coronavirus
10x
Hand
contamination
50x
Worker Error
100x
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THEBENEFITSOFINCORPORATINGHUMAN
FACTORSPRINCIPALSAREPOTENTIALLY
SIGNIFICANT
12
Sources:RiskandBenefitAnalysisofGainofFunctionResearchDraftFinalReportDecember2016
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SIMPLEAPPROACHESCANYIELDSIGNIFICANT
REDUCTIONINERRORS
40%
reduction
inerrors
Source:Haynes,AlexB.,etal."Asurgicalsafetychecklisttoreducemorbidityandmortalityinaglobalpopulation."NewEnglandJournalofMedicine
360.5(2009):491499.
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NASARECENTLYFACEDHUMANERRORDATA
SHORTAGE&INTENSIFIEDDATACOLLECTION
Sources:Chandler,F.,Heard,I.A.,Presley,M.,Burg,A.,
Mideen,E.,&Mongon,P.(2010).NASAhumanerroranalysis.
NationalAeronauticsandSpaceAdministration,FinalReport.
14
BHF1
SURVEYOFLABORATORYAQUIRED
INFECTIONSINEUROPE(68INSTITUTIONS)
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Reportsthat95%involvedhumanerror
15
Slide 15
BHF1
What is the stat of 95% based on? And how does the arrow tie to human error?
Beth HF, 3/10/2016
RecommendsMultifaceted
interventions
Modelingofthebehaviorby
supervisorsandcoworkers,
Implementationofwritten
handwashingpolicies
Reductionofexitfrequency
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THEFIELDISPOSITIONEDTOPROVIDERELEVANT
DATABUTMOREBSL2/3WORKISNEEDED
[cuttingcorners]were
mainlyfoundtobedueto
situationalandorganizational
factors.Forexample,time
pressure,workload,staffing
levels,training,supervision,
andavailabilityofresources
HumanfactorsthatleadtononcompliancewithstandardoperatingproceduresSimonBates&JustinHolroyd
HealthandSafetyLaboratoryHarpurHillBuxtonDerbyshireSK179JNhttp://www.hse.gov.uk/research/rrpdf/rr919.pdf
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CONTEXTDATAAREALSOIMPORTANT(FOCUS
GROUPSIN6UKCL3LABS)
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STAFFINUSIMPACTEDBYGROWTHOF
ENVIRONMENTALHEALTHANDSAFETYREGS
18
Sources:GreenBlueascitedinSimpson,S.A.(2016).Astudyofsafetyclimateandemployees'trustoftheirorganizational leadershipinuniversityresearchlaboratories.
RECOMMENDRIGOROUSDATAAND
SOPHISTICATEDANALYTICSTOREDUCERISK
Copyright2016
Suggestcreatingnationalreportingstandardsthatgo
beyondthemostsignificantadverseevents
Collectingnearmissesisreallyimportant(thebulkof
theiceberg)
Sometypesofeventsarerare(wethink)socollecting
acrossmultiplebodieswouldbeprudent
Optimalsolutionistostandardizedatainputs;this
wouldincreasethepoolofinformationforanalysisand
theapplicabilityofanydatadrivenapproachesto
reducingrisk
19
Sources:GoogleSelfDrivingcarProjectMonthlyReport,November2016
BHF2
LOOKINGFORWARDTOFURTHERREDUCTION
OFRISKTHROUGHSOPHISTICATEDANALYTICS
Copyright2016
Forexampleanalyticsdrivenmodelsofwhenandwhen
adverseeventsaremorelikelytooccurandunderwhat
circumstances
Inotherindustries,thesetypesofmodelshaveleadto
designstofurtherlowerrisk.Theycanalsoleadto
enhancedresearchproductivity.
Wehaveadditionalopportunitiestodirecttrainingand
otherinterventionswheretheyareneededmost
20
Slide 20
BHF2
Do you want to add the police example here? I think this will drive home the point that reporting on the near misses is a predictor of
which labs have the highest risk levels.
Beth HF, 3/10/2016
6Years
2Millionmiles
17Minor
accidents
21
Sources:GoogleSelfDrivingcarProjectMonthlyReport,November2016
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RISKREDUCEDTHROUGHRIGOROUSDATA
ANDSOPHISTICATEDANALYTICS
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THEROLEOF HUMANFACTORS
ThankYou
Enhancepreparedness
Preventsignificantaccidents
Mitigateconsequences
Improveproblemsolvingafteradverseevents
Identifydataneededtosupportrigorousanalysis
Supportdecisionsregardingallocationoflimitedresources
Sunshineimplicitrisksadoptedbyateam
Sunshinehiddenorunderappreciatedbenefitsofexisting
practice
Robustbiosafetyenvironmentcanhardenbiosecuritytarget
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ORGANIZATIONSBENEFITFROMHUMAN
FACTORFOCUSAPARTFROMRISKREDUCTION
E.g.,acceptablerisksareadoptedprojectby
projectorlabbylab
Wetendtounderestimate
cumulativerisk
Weareoptimisticabout
ourcapacitytocontrol
localrisk
Needtobeawareof
potentialtoaccruebenefits
(science)&externalizerisks
(publichealth)
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BEWAREOFOURLIMITEDCAPACITYTO
UNDERSTANDANDMANAGERISK