Master Recherche Mention Génie Industriel ECP

Master Recherche Mention Génie Industriel ECP
Spécialités MoMac/OSIL
2010 - 2011
Formulaire de sujet de mémoire thématique
(à renvoyer à [email protected])
Spécialité du Master Recherche :
MoMac/OSIL
Titre du sujet proposé :
Exploring the use of « Human error » models for engineering healthcare practice
Nom de l’organisme ou de l’entreprise qui propose le sujet : ECP
Nom du resp. du sujet (encadrant) : Marija Jankovic, Enrico Zio
Numéro de téléphone du resp. du sujet :
Email du resp. du sujet :[email protected] ,[email protected]
Contexte et présentation du sujet :
Patient safety is a critical element of quality environment in healthcare. There is a great deal of variability
of errors in the medical system, though the causes are very grave and can lead to the death of the patient.
The report of Institute of Medicine on errors is rather eloquent on the subject: between 44 000 and 98 000
patients in USA die in hospitals due to the medical errors; the costs for the adverse events are estimated
between $36.6 bilion and $50 bilion and $17-$29 bilion for preventable events; accidents that involve
healthcare professionals conduct to 7 000 deaths every year.
Objectifs et résultats attendus de l’étude bibliographique :
“Human error” has been identified as one of the major bottlenecks of patient safety. The objective of this
study is to explore the opportunity of using the rich research body of modeling work in nuclear, aerospace
and industrial engineering as a means for understanding human errors in the medical system. A number of
methods have been developed, which offer a systematic way of analyzing the contextual scenario of human
errors and provide the possibility of proactively preventing and managing them. The challenge of the
project lies in the identification of the similarities and differences with the healthcare, and of the instances
in which transfer of knowledge and models to the healthcare system is possible, and under what
adaptations.
Connaissances requises éventuelles :
Perspectives éventuelles (publications? stage de mémoire de recherche ? thèse ? embauche ?) :
Depending on the results and the quality of work, publication of the work would be considered and
welcomed.
References:
“The error is human: Building a Safer Health System”, Linda T. Kohn, Janet M. Corrigan, and
Molla S. Donaldson, 2000, Committee on Quality of Health Care in America, INSTITUTE OF MEDICINE
« Mesure de la sécurité des patients dans les établissements de santé : État des lieux et perspectives »,
Direction de la recherche, des études, de l’évaluation et des statistiques DREES, n° 89 – mai 2009
Swain A.D., Guttman H.E., “Handbook of human reliability analysis with emphasis on nuclear power plant
applications”, NUREG/CR-1278, 1983
Podofillini L., Dang V.N., Zio E., Baraldi P., Librizzi M., “Improving the traceability and repeatability of
dependence assessment in human reliability assessment: a new method”, 2007, Reliability Engineering and
System Safety.
Hannaman G., Spurgin A., Lukic Y., “Human cognitive reliability model for PRA analysis”, Technical report
NUS-4531, Palo Alto California Electric Power Research Institute, 1984.
Hollnagel E., Cognitive reliability and error analysis method (CREAM). Elsevier Science Ltd., 1998.
Marseguerra M., Zio E., Librizzi M., 2006. “Quantitative Developments in the Cognitive Reliability and Error
Analysis Method (CREAM) for the Assessment of Human Performance”, Annals of Nuclear Energy 33 (2006)
894–910.
Forester J. A., Kiper K., Ramey-Smith A., “Application of a New Technique for Human Event Analysis
(ATHEANA) at a Pressurized Water Reactor”, PSAM 4, New York City, September 13-18, 1998.
Bieder C., Le Bot P., Desmares E., Cara F. and Bonnet J.L., “MERMOS : EDF’s New Advanced HRA Method”,
PSAM 4, New York City, September 13-18, 1998.