Human reliability analysis in healthcare: Application of the cognitive reliability and error analysis method (CREAM) in a hospital setting

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dc.contributor.advisor Rantanen, Esa Deeter, Joey 2012-06-18T14:27:44Z 2012-06-18T14:27:44Z 2012-06-04
dc.description.abstract Patient safety is a concern within the healthcare domain as it is estimated that tens of thousands of people die annually from preventable medical errors. For over ten years, traditional Human Reliability Analysis (HRA) techniques (e.g., Root Cause Analysis and Failure Mode and Effect Analysis) have been used in hospitals nationwide in an attempt to explain why these errors occur and what can be done to prevent them. Still, patient safety has not improved significantly. Traditional HRA techniques are limited as analysis tools. They do not consider the context in which workers operate. They are also not based on a valid psychological model that could explain human cognitive function. The Cognitive Reliability and Error Analysis Method (CREAM) is an HRA technique that allows analysts to examine worker actions through the context of performance-shaping factors. The CREAM also employs a cognitive model to explain cognitive failures. This research used the CREAM to re-analyze events containing identifiable error modes that were previously analyzed by hospital team members using the RCA technique. The results of the re-analyses using the CREAM were compared with the previous analyses from RCA events. Additionally, several RCA events were observed and detailed written narratives of the observations were used to perform further independent analyses by three independent analysts in an effort to calculate inter-rater agreement. The results exposed a gap within categories of causal factors between the two techniques. The CREAM identified organizational factors as contributing to error in the events whereas those factors were either minimized or ignored in the RCA. The results also failed to demonstrate any significant inter-rater agreement among independent analysts performing the CREAM analyses. Due to serious data limitations, detailed analyses using the CREAM were not possible. en_US
dc.language.iso en_US en_US
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dc.subject Healthcare en_US
dc.subject Human reliability analysis en_US
dc.subject Medical error en_US
dc.subject NYPORTS en_US
dc.subject Organizational factors en_US
dc.subject Root cause analysis en_US
dc.subject.lcc R729.8 .D44 2012
dc.subject.lcsh Medical errors--Prevention en_US
dc.subject.lcsh Medical errors--Psychological aspects en_US
dc.subject.lcsh Biomedical engineering en_US
dc.subject.lcsh Human engineering en_US
dc.subject.lcsh Reliability (Engineering) en_US
dc.title Human reliability analysis in healthcare: Application of the cognitive reliability and error analysis method (CREAM) in a hospital setting en_US
dc.type Thesis en_US College of Liberal Arts en_US
dc.description.department Department of Psychology en_US

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