Human Reliability Analysis – Cardiac Hospital Case Study with New Applicability

摘要

Cardiac care requires 24-hour monitoring of the condition of each cardiac patient’s condition. This isrnaccomplished through evaluation and feedback of the patients’ many critical physiological parameters.rnThis monitoring is increasingly being accomplished through wireless technology. Technicians at remoternmonitoring stations continuously monitor the many critical readings necessary to assess a cardiacrnpatient’s status. The system is set up such that when one of the measured parameters exceeds orrnundershoots its acceptable range, thus indicating the development of a potentially life-threateningrncondition, an alarm comes in to the central monitoring station. The technicians assess and interpret thernalarm and contact the nurses on the cardiac floor as necessary. The nurse assesses and then addresses thernpatient’s needs or potential cardiac condition. This type of system and the required responses are veryrnsimilar to the development of upset conditions in a chemical or minerals processing plant. This is arncritical system that must operate properly in order to assure the well-being of the cardiac patients underrnthe hospital’s care (or the continued safe operation in a process plant). This collection of humans andrntechnology would appropriately be defined as a system. Therefore, when an incident occurred (in thernhealth care industry, this is called a sentinel event); an appropriate systems analysis was completed.rnThis study was done after a case in which a patient’s cardiac condition was not addressed adequately.rnWhile a root cause analysis (RCA) was done by the hospital to determine how and why the condition wasrnnot addressed, the RCA is outside the scope of this paper.rnThe analysis included a complete ergonomic assessment, a task analysis, a workload and task engagementrnassessment, an evaluation of training, an analysis of equipment reliability, and a fault tree analysis tornbring together a reliability analysis of the entire system. The results of the analysis showed that therernwas a probability of 1.63 × 10~(-2) that the system would fail again and another patient could experience anrnunaddressed cardiac condition. With so many interdependent system components, it is difficult to reducernthis likelihood. However, through many physical, process, and task-based changes made by the hospitalrnadministration, as well as diligent oversight and regular performance data analysis, in the five years sincernthe initial study, the hospital has not experienced another sentinel event to which the system failed tornrespond.