MIDTERM Assignment

Midterm: Human error and detection and prevention

Author: Pranav Reddy Vuppunuthula

Professor: Paul G.Ranky

1. Lifting up of loads in industries:


Problem:

Generally in industries, heavy loads are not lifted manually. They are lifted by cranes or vertical lifts which are operated by workers. They are lifted with the power of a motor. Usually, these cranes contain two buttons one in green color and the other in red color. The green button is used to operate the crane to lift the required material to the required height, whereas the red button is used to stop the movement of the crane after lifting it to the required height. But in case, if the worker forgets to press the red button at the required time, the material may fall down which causes injury to the workers. Also any power failure in this process may also result in unwanted results. This leads to a human error.

Detection:

The vertical lift should be stopped at a particular desired height for the job to take place but the mistake in operation by the worker will lead to continuous movement of the crane upwards. This leads to collision of the crane with the roof causing tremendous noise. Also, there is a chance of the material falling down on the job floor which will cause serious injuries to the people on the job floor. So this problem can be detected easily by visual inspection or by the video surveillance.

Prevention:

To prevent this kind of dangerous incident in industries, a sensor has to be placed in the crane which is used for lifting. By doing so, the sensor will sense the location of the material to be placed and will deliver it exactly even if the worker forgets to hit the red button at the required time. This means that a small programming should be done for the sensor to exactly provide the information as to where or at which height the action of the crane should be stopped such that no danger occurs. This will also be useful in the case of power failures as the sensor will stop the crane immediately without the material being destroyed.

2.Pollution:

Detection:

 Pollution is the introduction of contaminants into the natural environment that causes adverse change.  Specifically, the issue of water and air pollution has been a problem to society for many years due to its effect on human and environmental health.  For one to detect air pollution, all that one has to do is to observe motor vehicle emissions that come out of the exhaust pipes.  Another way to detect pollution is to observe smoke that comes out of chemical plants, coal-fired power, oil refineries, petrochemical plants, nuclear waste disposal activity, incinerators, large livestock farms (dairy cows, pigs, poultry, etc.), PVC factories, metals production factories, plastics factories, and other heavy industry machines in industrial areas.

Prevention: 

 Preventing pollution will help reduce respiratory diseases, cardiovascular disease and chest pain experienced by people living around industry areas.  The way to reduce or control pollution is to formulate strict environmental laws and educate people about the effect of environmental. All upcoming cars must be built with a consideration of the human and environmental health factors.  One way to do this is build gas-electric hybrid cars to reduce the use of gas and as a result reduce pollution.  Installing dust collector in an industry is another way of preventing pollution.  A dust collector is a system used to enhance the quality of air released from industrial and commercial processes by collecting dust and other impurities from air or gas. Designed to handle high-volume dust loads, a dust collector system consists of a blower, dust filter, a filter-cleaning system, and a dust receptacle or dust removal system.  Another major way that industries can prevent pollution in general is to recycle all waste materials.

3. Measuring Hyperglycemia

Problem:

       Diabetes has become a very common disease in older people while its laboratory tests are very costly. The problem should concern with the patient’s routine checkup. It’s a human error when he thinks about his disease many times and tries to do extra caring while he is using medicine regularly. As a solution, the patient measure hyperglycemia with glucose meter that show the results of patient about his routine sugar. They use different products on the behalf of company’s advertisement and trust. A person uses it without its experience and as a result gets a wrong result.

Detection:

As we know that average people cannot bear the medical expenses, especially when they need to give laboratory tests many times. The problem is detected when they get wrong result because proper time and quantity of blood is required. Sometimes the problem detects in the strips because the same time the strips provide different results.

Prevention:

We can prevent from this problem using quality products and before using we need to sufficient knowledge about strips and timing etc. The quality products have good standard and real results and in this way we can prevent from this kind of human error. 

4. Prescription errors

Detection:

Prescribing errors are common, with systematic reviews suggesting that as many as 50% of hospital admissions and 7% of medication orders are affected. In recent studies, prescribing errors have been found to affect approximately 9–15% of medication orders for hospital inpatients in the UK. Over one-third of 651 patients were found to have a prescribing error occurring at hospital admission in the USA. Prescribing errors are also prevalent in primary care, affecting 37% of 9385 prescriptions in the USA, and one in eight patients (1 in 20 prescription items) in the UK. A study in the Netherlands evaluating medication omission errors in elderly patients admitted to hospital reported adverse consequences in 21% of 100 patients.

Human error in healthcare may be considered in the context of individuals or health systems. While personal factors such as forgetfulness, inattention, poor motivation, carelessness, negligence and recklessness are important, a health systems approach more comprehensively addresses recurrent errors and organization factors and processes which may give rise to that error.

Prevention:

Acquisition of information through error-reporting systems is a prerequisite for preventing prescribing faults and prescription errors, as is the adoption of shared criteria for the appropriateness of procedures. Error-reporting systems, both internal and external to healthcare institutions, have been widely used. Reporting is usually voluntary and confidential, but must be timely and evaluated by experts, in order to identify critical conditions and allow systems analysis. Prescribers should be informed and become aware of errors that have been made in their environment and of the conclusions of the analysis.

Spontaneous reporting is about 10 times less effective in detecting errors and potential adverse effects than active interventions, such as chart review and patient monitoring. Active, systems-oriented interventions aimed at improving processes, rather than individual performance, should therefore be advocated. 

There are three major intervention strategies can be adopted:

⦁ Reduction of complexity in the act of prescribing by the introduction of automation;

⦁ Improved prescribers' knowledge by education and the use of on-line aids;

⦁ Feedback control systems and monitoring of the effects of interventions.

5.Blind Spot while Driving:



Problem:

Generally while driving, a blind spot is an area around the vehicle that cannot be observed directly by the driver while at controls. They exist in almost all varieties of vehicles like cars, trucks, motor boats and aircrafts. It is nothing but an invisible area to the driver while he is in normal driving position, which can lead to accidents if proper attention is not given. Side view mirrors alone are not sufficient to avoid this danger, because during lane change the car in the next lane behind us is not visible in our side view mirror after it crosses half the length of our car. So, due to lack of view there may be a chance of collision with the vehicle beside us if we try to change the lane unknowingly.



Detection:

I have encountered the problem of blind spot when I recently started driving in the New Jersey and few other highways. While I was driving on the freeway, there were some areas in the lane where passing and lane change was allowed and there were some restricted areas where lane change was restricted.  This problem can be easily detected by looking out from the window instead of relying only on the rear view mirror and side view mirrors. In actual practice, the side view or rear view mirror shows no vehicle beside, but if seen through window, some vehicle can be found which is crossing in the next lane and has already crossed half of the cars length. If we turn the vehicle to next lane, without proper care, then there will always be a scope for accident by which a blind spot problem can be detected.

Prevention:

The best way to prevent this problem is being aware of blind spot which is generally accomplished because of the road driving test for obtaining a driver’s license. If the side view mirrors are properly adjusted, then blind spots do not exist which can greatly reduce the possibility of accidents. Bending forward and looking out to check whether there is any vehicle in the next lane, before changing the lane will greatly help in avoiding the problem of blind spots. Also using signals well in advance before changing lines will really help in avoiding accidents. This makes other road users aware that about the lane changes.

6. Garbage

Problem: 

 People throw garbage anywhere while walking off the road. This isn’t mostly seen in The United States but still seen a lot in India and many other countries. This leads to various problems like diseases and a spread of foul smell throughout that area.

Detection: 

 I have seen many people who just throw garbage outside the garbage bin in India and United States. This is very much prominent in India due to Population explosion. But it is controlled in US due to low population and proper management skills. I have seen it myself when people go to throw garbage in the dump zone they just do not walk inside it they throw it from outside due to which 60% of the garbage is dumped outside the bin and due to this everyone dump their trash outside and this causes the development of various harmful insects which transmit disease in the nearby environment. I have been a target of such insects when I was attacked by dengue due to uncleanliness in the area nearby. This is the main reason which causes epidemics throughout a particular area in which many people are affected and even some of them lose their lifes due to this. 

Prevention:  

 This can be prevented by following the same type of management which is used in the states and is a very good way of avoiding spread of diseases and maintaining a healthy environment. If there are bigger dump zones and are cleaned frequently they can maintain a healthy environment in which people can reside.

7. Fire Accidents

Problem:

Accidentally caused fires in houses and multi-storied buildings and at any workplace.

Detection:

 A smoke detector is typically a device designed to detect black smoke. Black smoke is caused only due to burning of an object. Hence this device helps preventing fire accidents. I the US a recent census taken by the National Fire Protection Association says that at least 2/3rd of the deaths causes by fire accidents are because of malfunctioning fire or smoke detectors. This is definitely a human error not to notice a fire developing. Safety is always a matter of when and how. Hence the smoke detectors will set of an alarm at a point when the fire can still be put off and prevent a major accident. The smoke detector is definitely a very effective human error prevention technique.

Prevention:

  Human are definitely receptive to heat and sound. But when a human is sleeping he is half dead. It is a general human tendency to lose control of his senses and go in deep sleep but in real life if a small fire develops during that moment it could prove to be fatal. This is definitely a human error not to notice a fire developing. Safety is always a matter of when and how. Hence smoke detectors will set of an alarm at a point when the fire can still be put off and prevent a major accident. The smoke detector is definitely a very effective human error prevention technique.

8. Weather Forecasting:


Problem:

Weather forecasts are those which we generally depend on daily in our lives. Each and every country has its own set up of weather forecasting techniques and a pool of highly intellectual people working on it. Lot of technology has been incorporated in this field to ensure perfect prediction. However, there is every possibility of human error in this case as no one earth can exactly predict the nature and its behavior. Weather forecasting techniques are useful to detect the future conditions only through a statistical data, but in real practice any drastic changes are possible suddenly which cannot be even forecasted. So due to this natural behavior, many a times errors are interpreted in weather forecasts.

Detection:

Detection of this type of error is highly difficult because natural things change very suddenly without any specific pattern. Sometimes clouds appear in a particular area and suddenly disappear in a short while. In this case, the forecast of rain seems to be incorrect due to sudden shift of the clouds from the expected region. When a disaster is detected by the machines, some people refuse to accept the reality of forecasting. In such case, a human error can be detected but the lives of those who ignore the warnings cannot be saved. As we have seen in the news, disasters and tragedies happen worldwide. For example, the big earthquake that occurred in Sichuan, China in 2008. The whole province was destroyed through that unpredicted earthquake. Nobody knew about that power of the earthquake, but it brought chaos to a lot of peoples’ lives and families.

9.Dispatching errors:



Problem:

These errors are quite common in many of the daily activities. Generally dispatching is the final part in any of the business. It means sending the right material to the right person in right quantity in right time which can increase customer satisfaction. Usually, a person know as dispatcher is responsible for carrying out these actions. In recent days, e-commerce has gained widespread attention among the people. The ease of online shopping has really helped many busy people to rely on that. But a common human error which has been identified in this case is that sometimes a wrong item reaches the customer which is caused due to carelessness of the person in charge for dispatching.

 

Detection:

I have personally experienced this issue when I have ordered a case for my IPhone 5S on Amazon, a couple of months ago. The product I received wasn’t matching the product which I actually ordered for. The design was entirely different and the model was a low end one which was to be returned back to them. In this case, the dispatcher could have mixed up the orders in a hurry and finally landed up in sending the wrong item to the customer. In these type of cases, the problem can be detected only through the feedbacks of the customers. Also, these type of issues should be addressed very effectively as they can impact the reputation of the company.

Prevention:

The mismatch in dispatching can be resolved by thorough inspection. Once the person who delivers the order packs it out for shipping, the supervisor must ensure that the item in the package matches the item ordered by the customer. Also, a bar code should be printed on the consignment which can be read and fed into the customer dispatch information so that all the details of the product shipped can be retained with the company. More advanced solution to this problem would be to store digital images of the item ordered so that the system matches the digital images of both the order placed and order packed and displays an error notification in the system before dispatch in case of mismatch.

10. Wastage of Electricity:

Problem:

 In our day to day life many of us forget to switch of the Lights and fans which are not being used at that particular time which causes the wastage of Electricity.

Detection:

 At the evening when I was leaving my room after switching OFF all the switches I figured out that the Light of my closet was ON. This causes the lot of electricity wastage as nobody is using at that time. This is where the right approach isn't used to switch OFF the unwanted switches of lights and fans. By doing this there will be a lot of saving of electricity which can be used further.

 Prevention:

  Immediately after leaving the place and seeing that there isn't anybody to use it further then switch off the useless switches so that forgetting of the same isn't the issue. Prevention can be taken by using the Occupancy sensors which switches off the Lights and fans when there is no one in the room.

 11. Industrial Cleaning Processes:



Problem:

This problem is very commonly found in many of the manufacturing industries. In industries, many of the cleaning processes take place regularly. Generally, they are done in huge cleaning machines which are highly automated. Such machines do not require the attention of humans once they are started and set to the required temperature. In this case, a common human error was shared with me by my friend who works in a manufacturing firm. The problem was with the setting up of wrong temperatures for required cleaning processes which resulted in poor cleaning.



Detection:

Industrial parts like crank case, transmission case, gears, shafts etc. require cleaning before and after their usage and sometimes as and when required. Certain parts require certain temperatures for cleaning process. All the cleaning processes do not take place at room temperate, but some require high temperature and some require low temperature. So the temperature setting should be done manually which requires high attention. In this case, improper cleaning can be seen as a human error because the workers are responsible for temperature setting which results in perfect cleaning. The desired output which will be very poor can be said as a detection method in this case. It can be more explicitly explained by the quality control people whereby they reject the material if it does not match the exact requirement.

Crank Shaft Cleaning Process 

Prevention:

The best way to resolve this issue is by placing sensors and thermostats at required positions to gain full control over the temperature maintenance. Suppose for example, any process requires a temperature of 50 degrees Celsius for its cleaning process and a worker tries to switch the process on at room temperature, then the sensor will get actuated and will not initiate the cleaning process which will protect the work piece. Similarly, a thermostat which is installed can avoid increase in temperature which is not desirable. Suppose, if the worker does not stop the process at the correct time, thermostat will get activated and will stop the temperature increase which will prevent from overheating.  

12. Filling up fuel, coolant and lubricant in automobile industry:



Problem:

This problem is a real time issue which I came across during my visit to Mahindra Automotive Company, India. Basically, this is a company which produces various types of commercial and personal vehicles which suit various needs of customers. In any vehicle that is manufactured by the company, diesel, lubricant and coolant should be maintained in the required levels so that optimum performance is attained. Generally, these were filled manually by humans where the possible error was with filling up wrong quantities of each of them. This happens because the person may forget the amount of diesel, coolant or lubricant previously filled, whereby he fills more than or less than the required quantity which affects the performance of the vehicle.

                                           Filling Lubricant in Car

Detection:

This problem can be easily identified by checking the amount of fuel consumed, checking the lubricant level and efficiency of the vehicle. Under optimal conditions, the vehicle should perform as per the specifications issued during manufacturing. But if the coolant level is low the heat from engine does not dissipate and thereby increases the engine temperature which results in a blow out or engine failure. This can be detected by measuring the coolant levels. Similarly for perfect operation of pistons and cylinders, exact amount of lubricants must be filled each time when required. So for doing these activities exactly, there must be a previous history of the levels of each item filled which cannot be accomplished by humans.

Prevention:

As each variant requires different levels of fuel and lubricants, it is highly impossible for humans to remember the requirements of all variants. This particular industry produces various types of vehicles, wherein each variant has a different type of requirement. So, to avoid this problem, a bar code has to be created for each variant by feeding the data of that particular vehicle. This bar code contains the complete details of the vehicle along with the amount of diesel, coolant and lubricant required. The interesting feature is that the previous history can be tracked easily by scanning the bar code. This bar code will be printed on an access card which will be specific to each vehicle so that, when the any vehicle’s access card is scanned at the filling station, the person can feed the exact amount of all the three items which enhances the performance of the vehicle. Also this bar code system facilitates the user to check the present levels of lubricants and coolants in the engine which generally cannot be found out like the diesel levels present on the front panel of the vehicle.



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