W2016 Test 1 Marking Guide

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School

University of Waterloo *

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Course

162

Subject

Mechanical Engineering

Date

Jan 9, 2024

Type

pptx

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Uploaded by MinisterSkunk3903

BME 162 Test 1 Answer Key

1 mark for the correct approach, 1 mark for a good explanation why. Question 1 (Lin) Solution a. Root cause analysis. This looks for the original causes of an accident (as well as the factors that let it proceed). b. Accimap analysis. This looks at risk management, including government and organizational factors. c. Swiss cheese model. This looks at latent factors and how they can line up to allow an accident to occur. d. FMECA. This assesses risks by frequency and severity, to calculate the criticality of various types of events.

Question 2 (Murat) While you could come up with additional slices and holes, We were looking for 3 major and important slices (and holes): • Triage / diagnosis layer (hole: incorrect assessment) • X Ray clinic layer (hole: busy day) • Patient age (hole: weaker immune system) You should mention that the incident occurred because the holes lined up.

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Question 3 (Murat) What is expected: Cause and effect diagram (-1 mark if the chronology / logic has problems) Detailed analysis and discussion of the root causes (You could lose 2-3 marks if you skip this part and just put bullet point recommendations. Some of you have included the analysis in the recommendations section, that’s OK)

Question 3 (Murat) The analysis could include the following issues: • The machine was not responsive enough to recognize the change from e to x.i • The machine allows overrides despite in high intensity mode. • The error messages about the malfunction were not clear, hence lead the operator to override them. • The operator has no communication with the patient, and does not get feedback from the patient. Recommendations (Up to 2 marks) • Note: Operator error is never “the cause” (Check your lecture slides..), hence training is not a good recommendation. Better answers included a logical breakdown of events, discussed root cause(s) by looking into the user interaction, machine interface such as typing recognition, feedback and override, and provided recommendations based on this analysis.

1 mark-get the four levels right 1 mark per level-put something in the level that make sense(at least two points make sense each level in the first three) Question 4 (Lin) Solution: Use an accimap analysis to understand the spread of the Ebola virus (1)External Weak health care systems Lack of infrastructure Conflict and unstable governments (2)Organizational Infection control practices Burial ceremonies/culture (3)Physical actor events, processes and conditions Direct contact with humans, blood secretions, organs materials, Process of care taking, Process of burying (4)Outcomes Ebola virus transmission

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Question 5 (Lin) Solution: Frequency : 1-10%, 2-20%, 6-60%; Severity : 1-not sever, 2-moderate, 3-sever; Hand washing 6x1=6 Room 2x3=6 P2P 1x3=3 V2P 1x2=2 Conclusion : There are two failure modes to fix, hand washing and room cleaning. 1 mark-develop a probability/frequency scale 1 mark-develop a severity scale 1 mark-some simple math 1 mark-conclusion

Question 6 (Lin) Solution: 1 safety I looks at reduction of adverse events (1mark) 2 safety II looks at how things go well (1 mark) 3 safety 1 studies how adverse events occur (0.5 mark) and uses methods like accimap, rca, fta, swiss cheese (0.5 mark) 4 safety II requires studying when things go right (1 mark) Many more times when things go right than when they go wrong

Question 7 (Lin) Solution: 1 is a mistake, they never understood the situation correctly but took an action. (1 mark) 2 is a lapse, they understood correctly and had the right intention but forgot to take the action. (1 mark) 3 is an omission. They misunderstood that they needed to take action. (1 mark) You should identify team members one and/or 3 as being more serious. (1 mark)

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